MEDICARE: MISTY ANNETTE DIAZ

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1649055393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY ANNETTE DIAZ

Provider Business Mailing Address
First Line	:	2410 TAYLOR ST APT 22202
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-8458
Country	:	US
Telephone Number	:	972-730-6966
Fax Number	:

Provider Business Practice Location Address
First Line	:	2410 TAYLOR ST APT 22202
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-8458
Country	:	US
Telephone Number	:	972-730-6966
Fax Number	:

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

Provider Enumeration Date	:	08/30/2023
Last Update Date	:	08/30/2023

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Directions to “ MISTY ANNETTE DIAZ ” Practice Location

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