Healthcare Provider Details

I. General information

NPI: 1598341877
Provider Name (Legal Business Name): LIZETE DIAZ PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 W THUNDERBIRD RD STE I164
GLENDALE AZ
85306-3762
US

IV. Provider business mailing address

11968 W RIO VISTA LN
AVONDALE AZ
85323-7726
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-2100
  • Fax:
Mailing address:
  • Phone: 505-948-6647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number220014
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number220014
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number220014
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number220014
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number220014
License Number StateAZ
# 6
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number220014
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: