Provider Demographics
NPI:1003210626
Name:DIAZ, VANESSA (LSW)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 W BLACKWELL ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07801-3841
Mailing Address - Country:US
Mailing Address - Phone:973-328-3344
Mailing Address - Fax:973-328-6817
Practice Address - Street 1:18 W BLACKWELL ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-3841
Practice Address - Country:US
Practice Address - Phone:973-328-3344
Practice Address - Fax:973-328-6817
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6792104100000X
NJ44SC060634001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker