Provider Demographics
NPI:1043996804
Name:MAWAD, DIYALA BASSAM
Entity Type:Individual
Prefix:
First Name:DIYALA
Middle Name:BASSAM
Last Name:MAWAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 LAMPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3501
Mailing Address - Country:US
Mailing Address - Phone:929-603-3336
Mailing Address - Fax:
Practice Address - Street 1:179 LAMPORT BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3501
Practice Address - Country:US
Practice Address - Phone:929-603-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst