MEDICARE: EVELEEN DIMAGGIO-DIETZLER LCSW

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	62057	CA

General Provider Information

NPI Number	:	1417347550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVELEEN DIMAGGIO-DIETZLER LCSW

Provider Business Mailing Address
First Line	:	9278 HAWTHORNE AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92503-3831
Country	:	US
Telephone Number	:	951-237-9912
Fax Number	:

Provider Business Practice Location Address
First Line	:	9278 HAWTHORNE AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92503-3831
Country	:	US
Telephone Number	:	951-237-9912
Fax Number	:

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

Provider Enumeration Date	:	01/28/2015
Last Update Date	:	01/28/2015

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Directions to “ EVELEEN DIMAGGIO-DIETZLER LCSW” Practice Location

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