Healthcare Provider Details

I. General information

NPI: 1255455598
Provider Name (Legal Business Name): ISMAEL DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 W SHAW AVE STE 201
FRESNO CA
93711-3519
US

IV. Provider business mailing address

1690 W SHAW AVE STE 201
FRESNO CA
93711-3519
US

V. Phone/Fax

Practice location:
  • Phone: 559-334-6442
  • Fax:
Mailing address:
  • Phone: 559-334-6442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: