Provider Demographics
NPI:1215697982
Name:DIETRICH, COURTNEY ALEXIS
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ALEXIS
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6608 PHILMARK LN
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-7928
Mailing Address - Country:US
Mailing Address - Phone:360-581-2008
Mailing Address - Fax:
Practice Address - Street 1:221 W WYNOOCHE AVE UNIT B
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-4401
Practice Address - Country:US
Practice Address - Phone:360-581-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF61685787106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist