Basic Information
| Provider Information | |||||||||
| NPI: | 1962986455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETER | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 STARR AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436052456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199367600 | ||||||||
| FaxNumber: | 4199367606 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 STARR AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436052456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199367600 | ||||||||
| FaxNumber: | 4199367606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2018 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YP2500X | E.2102532 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0315253 | 05 | OH | MEDICAID |