Provider Demographics
NPI:1083440564
Name:DIETMAN, ANN MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:DIETMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7105 LITTLE WOLF RD NW
Mailing Address - Street 2:
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633-3024
Mailing Address - Country:US
Mailing Address - Phone:218-760-1976
Mailing Address - Fax:
Practice Address - Street 1:16123 GRANT UTLEY AVE. NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633
Practice Address - Country:US
Practice Address - Phone:218-335-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN308321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical