Healthcare Provider Details

I. General information

NPI: 1750286860
Provider Name (Legal Business Name): GENESIS DIAZ VEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COND CAMINITO 24 CARR 189 APR 2407
GURABO PR
00778
US

IV. Provider business mailing address

COND CAMINITO 24 CARR 189 APR 2407
GURABO PR
00778
US

V. Phone/Fax

Practice location:
  • Phone: 787-934-6133
  • Fax:
Mailing address:
  • Phone: 787-934-6133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15378
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: