Basic Information
Provider Information | |||||||||
NPI: | 1164887857 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIAZ | ||||||||
FirstName: | TYLER | ||||||||
MiddleName: | DUSTIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BARHAM | ||||||||
OtherFirstName: | TYLER | ||||||||
OtherMiddleName: | DUSTIN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4441 E KINGS CANYON RD | ||||||||
Address2: |   | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937023604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5596009180 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4441 E KINGS CANYON RD | ||||||||
Address2: |   | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937023604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5506009180 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2015 | ||||||||
LastUpdateDate: | 07/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | 37792 | CA | Y |   | Nursing Service Providers | Licensed Psychiatric Technician |   |
No ID Information.