Provider Demographics
NPI:1649366394
Name:MITZENMACHER, DIANE (LCSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MITZENMACHER
Suffix:
Gender:F
Credentials:LCSW
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 938
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-0938
Mailing Address - Country:US
Mailing Address - Phone:909-285-5205
Mailing Address - Fax:909-285-2103
Practice Address - Street 1:8300 UTICA AVE #155
Practice Address - Street 2:
Practice Address - City:RANCHO CUCUAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7605
Practice Address - Country:US
Practice Address - Phone:909-285-5205
Practice Address - Fax:909-285-2103
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS196551041C0700X
CABCD#295181041C0700X
CALCSW196551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical