Provider Demographics
NPI:1194988386
Name:DIECKHAUS, CHRISTOPHER MICHAEL (PT)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:MICHAEL
Last Name:DIECKHAUS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3045 S NATIONAL AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4268
Mailing Address - Country:US
Mailing Address - Phone:417-889-4800
Mailing Address - Fax:417-889-0980
Practice Address - Street 1:3045 S NATIONAL AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4268
Practice Address - Country:US
Practice Address - Phone:417-889-4800
Practice Address - Fax:417-889-0980
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008018542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist