Healthcare Provider Details

I. General information

NPI: 1932924834
Provider Name (Legal Business Name): LINDELL D DIEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SPRINGTREE DR STE 200
COLUMBIA SC
29223-8614
US

IV. Provider business mailing address

200 SPRINGTREE DR STE 200
COLUMBIA SC
29223-8614
US

V. Phone/Fax

Practice location:
  • Phone: 803-722-4975
  • Fax:
Mailing address:
  • Phone: 803-772-4975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number10155
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: