Basic Information
| Provider Information | |||||||||
| NPI: | 1285259010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | FELIPE | ||||||||
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| Credential: | RP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 S ROLLIE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LUPTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806211508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036972583 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5995 IRIS PKWY | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805046412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036972583 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2020 | ||||||||
| LastUpdateDate: | 06/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | NLC.0006396 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.