Healthcare Provider Details

I. General information

NPI: 1245720366
Provider Name (Legal Business Name): GERARDO JOSE DIAZ AMFT# 136318
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 1ST ST
WOODLAND CA
95695-4023
US

IV. Provider business mailing address

455 1ST ST
WOODLAND CA
95695-4023
US

V. Phone/Fax

Practice location:
  • Phone: 530-662-2211
  • Fax: 530-758-8490
Mailing address:
  • Phone: 530-662-2211
  • Fax: 530-758-8490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number136318
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: