Provider Demographics
NPI:1679318372
Name:DIETER, PATRICK
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:DIETER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10805 SUNSET OFFICE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1026
Mailing Address - Country:US
Mailing Address - Phone:314-277-4540
Mailing Address - Fax:
Practice Address - Street 1:10805 SUNSET OFFICE DR STE 201
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1026
Practice Address - Country:US
Practice Address - Phone:314-277-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024025113101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional