Provider Demographics
NPI:1164180303
Name:DIAZ DE LEON, BRIANDA LIZETH
Entity Type:Individual
Prefix:
First Name:BRIANDA
Middle Name:LIZETH
Last Name:DIAZ DE LEON
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 1:2612 VERANDAH LN APT 932
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-2647
Mailing Address - Country:US
Mailing Address - Phone:682-298-1569
Mailing Address - Fax:
Practice Address - Street 1:2612 VERANDAH LN APT 932
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-2647
Practice Address - Country:US
Practice Address - Phone:682-298-1569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61795101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health