1124354048 NPI number — CARISSA LYN DIETZLER LPC

Table of content: CARISSA LYN DIETZLER LPC (NPI 1124354048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124354048 NPI number — CARISSA LYN DIETZLER LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIETZLER
Provider First Name:
CARISSA
Provider Middle Name:
LYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROPER
Provider Other First Name:
CARISSA
Provider Other Middle Name:
LYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124354048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6001 RESEARCH PARK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53719-1176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-263-6100
Provider Business Mailing Address Fax Number:
608-262-9246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6001 RESEARCH PARK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53719-1176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-263-6100
Provider Business Practice Location Address Fax Number:
608-262-9246
Provider Enumeration Date:
10/28/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  5422 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)