Basic Information
| Provider Information | |||||||||
| NPI: | 1992422307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6800 PARK TEN BLVD STE 200S | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782134293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102611060 | ||||||||
| FaxNumber: | 2102611821 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 N FRIO ST BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102613001 | ||||||||
| FaxNumber: | 2107319661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2022 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 14713 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.