Basic Information
| Provider Information | |||||||||
| NPI: | 1871126805 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIEDRICK | ||||||||
| FirstName: | OLIVIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | S73W26385 MT RAINIER DR | ||||||||
| Address2: | |||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531899698 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | W129N7055 NORTHFIELD DR | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530510538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622535400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2020 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.