Provider Demographics
NPI:1114474210
Name:DIAZ, RAFAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:RAFAEL
Other - Middle Name:
Other - Last Name:DIAZ-JIMENEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1004 SOUTHWIND ST
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-6318
Mailing Address - Country:US
Mailing Address - Phone:805-610-3600
Mailing Address - Fax:
Practice Address - Street 1:1004 SOUTHWIND ST
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-6318
Practice Address - Country:US
Practice Address - Phone:805-610-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2022-05-17
Deactivation Date:2017-10-25
Deactivation Code:
Reactivation Date:2017-11-13
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA986221041C0700X
CALCSW986221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health