Provider Demographics
NPI:1174606982
Name:DIETRICH, SCOTT RYAN (EDD, ATC)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:RYAN
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:EDD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11300 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33161-6695
Mailing Address - Country:US
Mailing Address - Phone:305-899-4818
Mailing Address - Fax:
Practice Address - Street 1:11300 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33161-6695
Practice Address - Country:US
Practice Address - Phone:305-899-4818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0036822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer