Basic Information
| Provider Information | |||||||||
| NPI: | 1952967853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITZEL | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N SAGE ST APT 11 | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490064061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696973317 | ||||||||
| FaxNumber: | 2696973317 | ||||||||
| Practice Location | |||||||||
| Address1: | 5629 STADIUM DR STE B | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490091952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695443270 | ||||||||
| FaxNumber: | 2695443288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2019 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801104194 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.