Healthcare Provider Details

I. General information

NPI: 1902447469
Provider Name (Legal Business Name): MICHELLE DIAZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2019
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3309 N OCONTO AVE
CHICAGO IL
60634-3536
US

IV. Provider business mailing address

3309 N OCONTO AVE
CHICAGO IL
60634-3536
US

V. Phone/Fax

Practice location:
  • Phone: 773-895-0753
  • Fax:
Mailing address:
  • Phone: 773-895-0753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180015525
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: