Provider Demographics
NPI:1457750739
Name:DIEBEL, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DIEBEL
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 1:1375 R DALE WERTZ DRIVE
Mailing Address - Street 2:PO BOX 312
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413
Mailing Address - Country:US
Mailing Address - Phone:989-269-9293
Mailing Address - Fax:
Practice Address - Street 1:1375 R. DALE WERTZ DRIVE
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-1365
Practice Address - Country:US
Practice Address - Phone:989-269-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802088257104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker