Healthcare Provider Details

I. General information

NPI: 1609193986
Provider Name (Legal Business Name): GLORIANGIE DIAZ MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 3 BOX 2612
TOA ALTA PR
00953-6405
US

IV. Provider business mailing address

RR 3 BOX 2612
TOA ALTA PR
00953-6405
US

V. Phone/Fax

Practice location:
  • Phone: 787-466-5294
  • Fax:
Mailing address:
  • Phone: 787-466-5294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3370
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: