MEDICARE: MS. MITZI AUDRA DIESING MSW, LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801083573	MI
2	104100000X	Social Worker	6801083573	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	718982000	OTHER	MI	MAGELLAN STATE OF MI
2	8008970860	OTHER	MI	TRADITIONAL BCBS

General Provider Information

NPI Number	:	1073568374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MITZI AUDRA DIESING MSW, LMSW

Provider Business Mailing Address
First Line	:	1200 N. WEST AVE.
Second Line	:	SUITE 810
City	:	JACKSON
State	:	MI
Zip	:	49202-2179
Country	:	US
Telephone Number	:	517-300-3985
Fax Number	:	517-816-1267

Provider Business Practice Location Address
First Line	:	1200 N. WEST AVE.
Second Line	:	SUITE 810
City	:	JACKSON
State	:	MI
Zip	:	49202-2179
Country	:	US
Telephone Number	:	517-300-3985
Fax Number	:	517-816-1267

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	10/20/2021

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