Provider Demographics
NPI:1386067981
Name:DIETRICH, SEPTEMBER
Entity type:Individual
Prefix:
First Name:SEPTEMBER
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SEPTEMBER
Other - Middle Name:
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11325 PEMBROOKE SQ STE 115
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4807
Mailing Address - Country:US
Mailing Address - Phone:301-719-1146
Mailing Address - Fax:301-645-5343
Practice Address - Street 1:11325 PEMBROOKE SQ STE 115
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4807
Practice Address - Country:US
Practice Address - Phone:301-719-1146
Practice Address - Fax:301-645-5343
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3693225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant