Healthcare Provider Details

I. General information

NPI: 1669272506
Provider Name (Legal Business Name): MARK WILLIAM DIEMER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 NORTHWOODS BLVD STE B-2
COLUMBUS OH
43235-4728
US

IV. Provider business mailing address

4021 TAMARACK AVE
GROVE CITY OH
43123-3805
US

V. Phone/Fax

Practice location:
  • Phone: 614-202-9359
  • Fax:
Mailing address:
  • Phone: 614-202-9359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: