Provider Demographics
NPI:1629941794
Name:DIETERLE, MAURICE MICHAEL (BA)
Entity type:Individual
Prefix:
First Name:MAURICE
Middle Name:MICHAEL
Last Name:DIETERLE
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 BACK VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-6817
Mailing Address - Country:US
Mailing Address - Phone:304-559-1597
Mailing Address - Fax:
Practice Address - Street 1:3575 KEITH ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4324
Practice Address - Country:US
Practice Address - Phone:423-458-6660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)