Provider Demographics
NPI:1124354048
Name:DIETZLER, CARISSA LYN (LPC)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:LYN
Last Name:DIETZLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:LYN
Other - Last Name:ROPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6001 RESEARCH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1176
Mailing Address - Country:US
Mailing Address - Phone:608-263-6100
Mailing Address - Fax:608-262-9246
Practice Address - Street 1:6001 RESEARCH PARK BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1176
Practice Address - Country:US
Practice Address - Phone:608-263-6100
Practice Address - Fax:608-262-9246
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5422101YP2500X
IL180007873101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional