Active NPI
Debra Dietrich, PSYCHOLOGIST
- School Psychologist
- Bloomington, IL
National Provider Identifier
1396947974
On this page
Key facts
NPPES NPI Registry- Primary specialty
- School Psychologist
- License
- 1062455
- Practice address
- 2404 E Empire St
Bloomington, IL 61704-3630 - Phone
- (309) 663-8275
- Fax
- (309) 687-2035
- NPI assigned
- Jun 5, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| School Psychologist | 103TS0200X | 1062455 | IL | Primary |
Addresses
Primary practice location
2404 E Empire St
Bloomington, IL 61704-3630
Mailing address
PO Box 991
Morton, IL 61550-0991
Phone (309) 678-3155
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1062455 | IL | MD | School Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1181001600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1396947974",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 991",
"city": "MORTON",
"state": "IL",
"postal_code": "615500991",
"telephone_number": "309-678-3155",
"fax_number": "309-672-6717"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2404 E EMPIRE ST",
"city": "BLOOMINGTON",
"state": "IL",
"postal_code": "617043630",
"telephone_number": "309-663-8275",
"fax_number": "309-687-2035"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DIETRICH",
"first_name": "DEBRA",
"credential": "PSYCHOLOGIST",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-06-05",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TS0200X",
"taxonomy_group": "",
"desc": "Psychologist, School",
"state": "IL",
"license": "1062455",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bloomington, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.