Provider Demographics
NPI:1972852614
Name:DIETZEL, SARA (MA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:DIETZEL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 SAND CREEK ROAD, SUITE 202
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513
Mailing Address - Country:US
Mailing Address - Phone:925-324-3950
Mailing Address - Fax:
Practice Address - Street 1:191 SAND CREEK ROAD, SUITE 202
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513
Practice Address - Country:US
Practice Address - Phone:925-324-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51356106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist