Healthcare Provider Details

I. General information

NPI: 1346354891
Provider Name (Legal Business Name): MIQUELA DIAZ PH. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIQUELA DIAZ PHD

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1676 SUNSET AVE FL 3
UTICA NY
13502-5416
US

IV. Provider business mailing address

185 MAIN ST
JORDANVILLE NY
13361-2729
US

V. Phone/Fax

Practice location:
  • Phone: 315-360-0527
  • Fax: 607-204-4120
Mailing address:
  • Phone: 315-360-0527
  • Fax: 607-204-4120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number016342-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: