Basic Information
| Provider Information | |||||||||
| NPI: | 1912446824 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | CHRISTINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2220 GIRARD STREET | ||||||||
| Address2: | |||||||||
| City: | SAN JACINTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516836596 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2220 GIRARD ST | ||||||||
| Address2: | |||||||||
| City: | SAN JACINTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925835301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516836596 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2017 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1222720216 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | TINA3003 | 01 | CA | BEHAVIORAL HEALTH | OTHER |