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General NPI Number Information
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NPI Number | 1649366394
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Entity Type | Individual
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Provider Name | DIANE MITZENMACHER LCSW
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Gender | Female
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 06/08/2023
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Provider Practice Location Address
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Address Line | 8300 UTICA AVE #155
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City | RANCHO CUCUAMONGA
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State | CA
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Zip | 91730-7605
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Country | US
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Telephone | 909-285-5205
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Fax | 909-285-2103
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Provider Business Mailing Address
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Address Line | PO BOX 938
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91729-0938
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Country | US
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Telephone | 909-285-5205
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Fax | 909-285-2103
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCS19655
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | BCD#29518
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW19655
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License Number State | CA
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