Provider Demographics
NPI:1063606705
Name:DIEBOLD, D.J. (DONALD) JAY (LISAC)
Entity type:Individual
Prefix:
First Name:D.J. (DONALD)
Middle Name:JAY
Last Name:DIEBOLD
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 E DESERT COVE AVE UNIT 141
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-5392
Mailing Address - Country:US
Mailing Address - Phone:480-650-1020
Mailing Address - Fax:
Practice Address - Street 1:4850 E DESERT COVE AVE UNIT 141
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5392
Practice Address - Country:US
Practice Address - Phone:480-650-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11485101Y00000X, 101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional