Provider Demographics
NPI:1750053773
Name:DIETZEN, CHANTAL
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:
Last Name:DIETZEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N CUYAMACA ST STE 110
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1865
Mailing Address - Country:US
Mailing Address - Phone:619-448-0420
Mailing Address - Fax:619-448-0131
Practice Address - Street 1:900 N CUYAMACA ST STE 110
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-1865
Practice Address - Country:US
Practice Address - Phone:619-448-0420
Practice Address - Fax:619-448-0131
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health