Healthcare Provider Details

I. General information

NPI: 1831740877
Provider Name (Legal Business Name): JAVIER DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 06/29/2023
Certification Date: 06/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 E WALNUT ST
PASADENA CA
91106-1878
US

IV. Provider business mailing address

2522 MAYNARD DR
DUARTE CA
91010-2213
US

V. Phone/Fax

Practice location:
  • Phone: 626-773-4364
  • Fax:
Mailing address:
  • Phone: 626-533-6060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: