Individual
KYLE SHANE DIETHRICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
COTA
Contact information
Practice address
400 COLLEGE AVE., TERRE HAUTE, IN 47802
(812) 917-2320
Mailing address
1402 WATERTREE RD., TERRE HAUTE, IN 47803
(812) 870-2416
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
99045856A
IN
Other
Enumeration date
03/03/2011
Last updated
03/03/2011
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