Basic Information
| Provider Information | |||||||||
| NPI: | 1821499062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | KYRENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 919 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913402957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182561124 | ||||||||
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| Practice Location | |||||||||
| Address1: | 919 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913402957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182561124 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2014 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103TC0700X | 32134 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.