Basic Information
Provider Information | |||||||||
NPI: | 1609326867 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIAZ | ||||||||
FirstName: | BEATRIS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10929 SOUTH ST STE 208B | ||||||||
Address2: |   | ||||||||
City: | CERRITOS | ||||||||
State: | CA | ||||||||
PostalCode: | 907035391 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629245526 | ||||||||
FaxNumber: | 5629241040 | ||||||||
Practice Location | |||||||||
Address1: | 10929 SOUTH ST STE 208B | ||||||||
Address2: |   | ||||||||
City: | CERRITOS | ||||||||
State: | CA | ||||||||
PostalCode: | 90703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629245526 | ||||||||
FaxNumber: | 5629241040 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2016 | ||||||||
LastUpdateDate: | 01/07/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor |   | 104100000X | ACSW83955 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.