Basic Information
| Provider Information | |||||||||
| NPI: | 1902579030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | MONIQUE | ||||||||
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| Credential: | ACSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14642 NEWPORT AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927806059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142470300 | ||||||||
| FaxNumber: | 7142591598 | ||||||||
| Practice Location | |||||||||
| Address1: | 14642 NEWPORT AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927806058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142470300 | ||||||||
| FaxNumber: | 7142591598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2021 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.