1073568374 NPI number — MS. MITZI AUDRA DIESING MSW, LMSW

Table of content: MS. MITZI AUDRA DIESING MSW, LMSW (NPI 1073568374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073568374 NPI number — MS. MITZI AUDRA DIESING MSW, LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIESING
Provider First Name:
MITZI
Provider Middle Name:
AUDRA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JANUKAITIS
Provider Other First Name:
MITZI
Provider Other Middle Name:
AUDRA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073568374
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 N. WEST AVE.
Provider Second Line Business Mailing Address:
SUITE 810
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49202-2179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-300-3985
Provider Business Mailing Address Fax Number:
517-816-1267

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 N. WEST AVE.
Provider Second Line Business Practice Location Address:
SUITE 810
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49202-2179
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-300-3985
Provider Business Practice Location Address Fax Number:
517-816-1267
Provider Enumeration Date:
05/24/2006

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: 1041C0700X , with the licence number:  6801083573 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 6801083573 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 718982000 . This is a "MAGELLAN STATE OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 8008970860 . This is a "TRADITIONAL BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".