Individual
CHRIS DIEDERICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
2040 N SHADELAND AVE, STE 250, INDIANAPOLIS, IN 46219-1711
(317) 355-5009
Mailing address
6626 E 75TH STREET, STE 500, INDIANAPOLIS, IN 46250-2890
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
39000598A
IN
1041C0700X
Clinical Social Worker
Primary
34004362A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000390191
ANTHEM BCBS PROVIDER PIN
IN
Enumeration date
07/18/2006
Last updated
04/12/2018
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