Healthcare Provider Details

I. General information

NPI: 1013184530
Provider Name (Legal Business Name): JESSICA M DIAZ MASTER OF ARTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 MANSFIELD AVE
WILLIMANTIC CT
06226-2027
US

IV. Provider business mailing address

132 MANSFIELD AVE
WILLIMANTIC CT
06226-2027
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-2261
  • Fax:
Mailing address:
  • Phone: 860-456-2261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: