Provider Demographics
NPI:1386166189
Name:DIETRICH, MARK ALLEN (MA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:ALLEN
Other - Last Name:DIETRICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:708 NE 6TH STREET
Mailing Address - Street 2:SAME
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34428-3704
Mailing Address - Country:US
Mailing Address - Phone:352-212-8350
Mailing Address - Fax:
Practice Address - Street 1:708 NE 6TH STREET
Practice Address - Street 2:SAME
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-3704
Practice Address - Country:US
Practice Address - Phone:352-212-8350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health