Basic Information
| Provider Information | |||||||||
| NPI: | 1649708793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | BRIAM | ||||||||
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| Credential: | RADT II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2088 E LAKESHORE DR APT 715 | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925304490 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 40700 CALIFORNIA OAKS RD | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925625795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518945072 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2017 | ||||||||
| LastUpdateDate: | 06/01/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | RII5751116 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.