Provider Demographics
NPI:1134482912
Name:DU, LISA DIAZ
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIAZ
Last Name:DU
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 1:624 E ELDER ST
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-3004
Mailing Address - Country:US
Mailing Address - Phone:760-451-4165
Mailing Address - Fax:760-731-1377
Practice Address - Street 1:200 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5424
Practice Address - Country:US
Practice Address - Phone:760-726-4900
Practice Address - Fax:760-631-0778
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA1009011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator