MEDICARE: C RUTH DIAZ LPC, PSY.D.

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	101YM0800X	Mental Health Counselor
2	101YM0800X	Mental Health Counselor	C4417	OR

General Provider Information

NPI Number	:	1174936298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	C RUTH DIAZ LPC, PSY.D.

Provider Business Mailing Address
First Line	:	839 SW GREEN AVE # 2
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-1024
Country	:	US
Telephone Number	:	503-319-1095
Fax Number	:

Provider Business Practice Location Address
First Line	:	1135 SE SALMON ST STE L5
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-3375
Country	:	US
Telephone Number	:	503-319-1095
Fax Number	:

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

Provider Enumeration Date	:	06/05/2014
Last Update Date	:	07/21/2022

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