Healthcare Provider Details

I. General information

NPI: 1568724334
Provider Name (Legal Business Name): KATELYN DIAZ MSED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 5TH AVE
NEW YORK NY
10029-3119
US

IV. Provider business mailing address

645 W 239TH ST 3E
BRONX NY
10463-1234
US

V. Phone/Fax

Practice location:
  • Phone: 212-426-3400
  • Fax:
Mailing address:
  • Phone: 718-578-7019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number1676482
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: