Provider Demographics
NPI:1265640338
Name:DIETZMAN, DIANA RAE (MA,LMFT)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:RAE
Last Name:DIETZMAN
Suffix:
Gender:F
Credentials:MA,LMFT
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 6860
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95502-6860
Mailing Address - Country:US
Mailing Address - Phone:414-545-9838
Mailing Address - Fax:707-443-3204
Practice Address - Street 1:7441 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4676
Practice Address - Country:US
Practice Address - Phone:414-545-9838
Practice Address - Fax:707-443-3204
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT23603106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist