Healthcare Provider Details

I. General information

NPI: 1972432011
Provider Name (Legal Business Name): ANDREISY TAVAREZ DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 HAZAEL ST
PROVIDENCE RI
02908-1314
US

IV. Provider business mailing address

138 HAZAEL ST
PROVIDENCE RI
02908-1314
US

V. Phone/Fax

Practice location:
  • Phone: 401-499-3251
  • Fax:
Mailing address:
  • Phone: 401-499-3251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: