MEDICARE: CRYSTAL RENEE DIAZ BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-19-38811	CA
2	103K00000X	Behavior Analyst	BEH-000834	AZ

General Provider Information

NPI Number	:	1013556844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL RENEE DIAZ BCBA

Provider Business Mailing Address
First Line	:	PO BOX 740780
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-0780
Country	:	US
Telephone Number	:	855-223-7123
Fax Number	:	619-374-7134

Provider Business Practice Location Address
First Line	:	13700 N DYSART RD STE 180
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85379-3319
Country	:	US
Telephone Number	:	855-223-7123
Fax Number	:	619-374-7134

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/26/2019
Last Update Date	:	02/04/2026

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