Provider Demographics
NPI:1063299337
Name:DIEFFENBACH COUNSELING, PLLC
Entity type:Organization
Organization Name:DIEFFENBACH COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:DIEFFENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:651-338-9435
Mailing Address - Street 1:2368 JOY AVE # NA
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7409
Mailing Address - Country:US
Mailing Address - Phone:651-338-9435
Mailing Address - Fax:
Practice Address - Street 1:2368 JOY AVE # NA
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-7409
Practice Address - Country:US
Practice Address - Phone:651-338-9435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health