Provider Demographics
NPI:1063805760
Name:MICHELLE DIEDRICHSEN
Entity type:Organization
Organization Name:MICHELLE DIEDRICHSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LAUREN
Authorized Official - Last Name:DIEDRICHSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-426-9319
Mailing Address - Street 1:295 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-3417
Mailing Address - Country:US
Mailing Address - Phone:775-426-9319
Mailing Address - Fax:
Practice Address - Street 1:295 E PARK ST
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-3417
Practice Address - Country:US
Practice Address - Phone:775-426-9319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV530557121Medicaid