Provider Demographics
NPI:1306327606
Name:DIETZ, CHARLES MILAN
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MILAN
Last Name:DIETZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 CLUBHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:WEIDMAN
Mailing Address - State:MI
Mailing Address - Zip Code:48893-8205
Mailing Address - Country:US
Mailing Address - Phone:517-488-5815
Mailing Address - Fax:
Practice Address - Street 1:1207 N CENTER RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48638-5509
Practice Address - Country:US
Practice Address - Phone:517-488-5815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other