Healthcare Provider Details

I. General information

NPI: 1609145291
Provider Name (Legal Business Name): MRS. MARIA R DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 SAN ANTONIO ST.
ANTHONY NM
88021
US

IV. Provider business mailing address

399 SAN ANTONIO ST
ANTHONY NM
88021-8707
US

V. Phone/Fax

Practice location:
  • Phone: 915-471-0417
  • Fax:
Mailing address:
  • Phone: 915-471-0417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: