Basic Information
| Provider Information | |||||||||
| NPI: | 1548878358 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETER | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAKER | ||||||||
| OtherFirstName: | DANIELLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5325 SW HALL BLVD | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970050531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038402396 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2645 PORTLAND RD NE STE 120 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973010200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033905637 | ||||||||
| FaxNumber: | 5033933135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2020 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | A5655 | OR | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | L11004 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.