Provider Demographics
NPI:1386512408
Name:DIESEL, SARA JEAN (MA)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:JEAN
Last Name:DIESEL
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 1:309 W FRONT ST UNIT 301
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2751
Mailing Address - Country:US
Mailing Address - Phone:810-965-4425
Mailing Address - Fax:
Practice Address - Street 1:921 W ELEVENTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3002
Practice Address - Country:US
Practice Address - Phone:810-965-4425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-29
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000979103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical