Healthcare Provider Details

I. General information

NPI: 1922152032
Provider Name (Legal Business Name): DESIREE ANN DIAZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 BROADWAY
NEWBURGH NY
12550-5515
US

IV. Provider business mailing address

141 BROADWAY
NEWBURGH NY
12550-5515
US

V. Phone/Fax

Practice location:
  • Phone: 845-568-5260
  • Fax: 845-568-5213
Mailing address:
  • Phone: 845-568-5260
  • Fax: 845-568-5213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number074244-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: