MEDICARE: CYNTHIA D DIAZ DE LEON PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	25303	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0023CE	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1174665186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CYNTHIA D DIAZ DE LEON PHD

Provider Business Mailing Address
First Line	:	7201 BROADWAY
Second Line	:	SUITE 218
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-3773
Country	:	US
Telephone Number	:	210-930-8988
Fax Number	:	210-930-8986

Provider Business Practice Location Address
First Line	:	7201 BROADWAY
Second Line	:	SUITE 218
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-3773
Country	:	US
Telephone Number	:	210-930-8988
Fax Number	:	210-930-8986

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	07/08/2007

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