Provider Demographics
NPI:1225888142
Name:WASSERBAUER, DIEDRICH
Entity Type:Individual
Prefix:
First Name:DIEDRICH
Middle Name:
Last Name:WASSERBAUER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12468
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85318-2468
Mailing Address - Country:US
Mailing Address - Phone:602-339-2457
Mailing Address - Fax:
Practice Address - Street 1:7075 W BELL RD STE A-1
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8546
Practice Address - Country:US
Practice Address - Phone:602-488-6104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-19445101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health