Provider Demographics
NPI:1134704737
Name:DIAZ, EMERSON NICOLAS (MA, NCC, PCAT)
Entity Type:Individual
Prefix:
First Name:EMERSON
Middle Name:NICOLAS
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MA, NCC, PCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 SIMPSON HIGHWAY 13
Mailing Address - Street 2:
Mailing Address - City:MENDENHALL
Mailing Address - State:MS
Mailing Address - Zip Code:39114-3076
Mailing Address - Country:US
Mailing Address - Phone:601-622-3056
Mailing Address - Fax:
Practice Address - Street 1:3112 SIMPSON HIGHWAY 13
Practice Address - Street 2:
Practice Address - City:MENDENHALL
Practice Address - State:MS
Practice Address - Zip Code:39114-3076
Practice Address - Country:US
Practice Address - Phone:601-622-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP1600X, 106H00000X, 101YA0400X
MS101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist