Healthcare Provider Details

I. General information

NPI: 1174452437
Provider Name (Legal Business Name): ELENA DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3584 JEROME AVE
BRONX NY
10467-1006
US

IV. Provider business mailing address

79 GLENRIDGE RD
GLENVILLE NY
12302-4523
US

V. Phone/Fax

Practice location:
  • Phone: 718-653-1537
  • Fax: 718-228-6993
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number41791-T
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: