Provider Demographics
NPI:1598573156
Name:DIETERS, OPAL LUNA
Entity type:Individual
Prefix:
First Name:OPAL
Middle Name:LUNA
Last Name:DIETERS
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 1:1611 S MURRAY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-4502
Mailing Address - Country:US
Mailing Address - Phone:719-316-3853
Mailing Address - Fax:
Practice Address - Street 1:1611 S MURRAY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80916-4502
Practice Address - Country:US
Practice Address - Phone:719-316-3853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0009925919104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker