Provider Demographics
NPI:1720236763
Name:DIETSCHE, SHARON SHANTI ISSURDATT (LCSW-C, LICSW)
Entity type:Individual
Prefix:MS
First Name:SHARON
Middle Name:SHANTI ISSURDATT
Last Name:DIETSCHE
Suffix:
Gender:F
Credentials:LCSW-C, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 SILVER SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-4608
Mailing Address - Country:US
Mailing Address - Phone:301-437-6869
Mailing Address - Fax:
Practice Address - Street 1:412 SILVER SPRING AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-4608
Practice Address - Country:US
Practice Address - Phone:301-437-6869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD167591041C0700X
DCLC500789001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0004834000Medicaid
MD3352072 00Medicaid