Provider Demographics
NPI:1205727104
Name:DIETZE, MCKENNA
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:DIETZE
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 1:365 N HONEY CREEK PKWY APT 300
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3484
Mailing Address - Country:US
Mailing Address - Phone:414-458-1111
Mailing Address - Fax:
Practice Address - Street 1:365 N HONEY CREEK PKWY APT 300
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53213-3484
Practice Address - Country:US
Practice Address - Phone:414-458-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-10
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator