MEDICARE: MAYRA LEONOR DIAZ LMFT

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	106H00000X	Marriage & Family Therapist	110966	CA

General Provider Information

NPI Number	:	1184000390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYRA LEONOR DIAZ LMFT

Provider Business Mailing Address
First Line	:	PO BOX 16442
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91615-6442
Country	:	US
Telephone Number	:	818-473-0945
Fax Number	:

Provider Business Practice Location Address
First Line	:	10737 RIVERSIDE DR
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602-2324
Country	:	US
Telephone Number	:	818-473-0945
Fax Number	:

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

Provider Enumeration Date	:	08/11/2015
Last Update Date	:	12/31/2020

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