Provider Demographics
NPI:1093541609
Name:DIETERLE, BRENNA
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:DIETERLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:ND
Mailing Address - Zip Code:58222-0129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4013 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:ND
Practice Address - Zip Code:58222-4014
Practice Address - Country:US
Practice Address - Phone:701-657-2163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2622235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist