Provider Demographics
NPI:1104476126
Name:DIETRICH, ZACHARY CLAYBORNE (PSYD)
Entity type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:CLAYBORNE
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 HOWSER RD
Mailing Address - Street 2:
Mailing Address - City:HENRYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47126-8616
Mailing Address - Country:US
Mailing Address - Phone:502-807-2481
Mailing Address - Fax:
Practice Address - Street 1:100 EXECUTIVE PARK STE 103
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4201
Practice Address - Country:US
Practice Address - Phone:502-313-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252672103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty