Provider Demographics
NPI:1053923318
Name:DIETMAN, RYAN DAVID (BS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:DIETMAN
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16127 LOGARTO LN
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-8771
Mailing Address - Country:US
Mailing Address - Phone:320-293-0274
Mailing Address - Fax:
Practice Address - Street 1:9001 E BLOOMINGTON FWY STE 143
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-3444
Practice Address - Country:US
Practice Address - Phone:952-777-4996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician