Provider Demographics
NPI:1073568374
Name:DIESING, MITZI AUDRA (MSW, LMSW)
Entity Type:Individual
Prefix:MS
First Name:MITZI
Middle Name:AUDRA
Last Name:DIESING
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:MS
Other - First Name:MITZI
Other - Middle Name:AUDRA
Other - Last Name:JANUKAITIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 N. WEST AVE.
Mailing Address - Street 2:SUITE 810
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2179
Mailing Address - Country:US
Mailing Address - Phone:517-300-3985
Mailing Address - Fax:517-816-1267
Practice Address - Street 1:1200 N. WEST AVE.
Practice Address - Street 2:SUITE 810
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:517-300-3985
Practice Address - Fax:517-816-1267
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010835731041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI718982000OtherMAGELLAN STATE OF MI
MI8008970860OtherTRADITIONAL BCBS
MIN93250003Medicare ID - Type Unspecified
MI8008970860OtherTRADITIONAL BCBS