Provider Demographics
NPI:1124567318
Name:DIAZ, CHARLES PATRICK (LMSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:PATRICK
Last Name:DIAZ
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 N TERRACE AVE APT 2E
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-2732
Mailing Address - Country:US
Mailing Address - Phone:917-696-4608
Mailing Address - Fax:
Practice Address - Street 1:300 W VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-5566
Practice Address - Country:US
Practice Address - Phone:432-263-7361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088716-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker