Basic Information
| Provider Information | |||||||||
| NPI: | 1639493471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETZEL | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | ANN-JAMISON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JAMISON | ||||||||
| OtherFirstName: | BETH | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | B.S. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1822 THRUSHWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490025760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693274388 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5500 ARMSTRONG RD | ||||||||
| Address2: | |||||||||
| City: | BATTLE CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490377314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699665600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2010 | ||||||||
| LastUpdateDate: | 03/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301014389 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.