Provider Demographics
NPI:1043409337
Name:DIESTLER, ADAM WILLIAM (MFTI)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:WILLIAM
Last Name:DIESTLER
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 VALLEY FORGE DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-2128
Mailing Address - Country:US
Mailing Address - Phone:209-473-4740
Mailing Address - Fax:
Practice Address - Street 1:1414 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1515
Practice Address - Country:US
Practice Address - Phone:209-468-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44418106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist