Provider Demographics
NPI:1083285290
Name:DIAZ, MELODY
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:DIAZ
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 1:3924 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92509-6611
Mailing Address - Country:US
Mailing Address - Phone:951-416-1572
Mailing Address - Fax:
Practice Address - Street 1:3924 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:JURUPA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92509-6611
Practice Address - Country:US
Practice Address - Phone:951-416-1572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171M00000X
CAMPSS-HYIRTF175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator