Provider Demographics
NPI:1174665186
Name:DIAZ DE LEON, CYNTHIA D (PHD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:D
Last Name:DIAZ DE LEON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 BROADWAY
Mailing Address - Street 2:SUITE 218
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-3773
Mailing Address - Country:US
Mailing Address - Phone:210-930-8988
Mailing Address - Fax:210-930-8986
Practice Address - Street 1:7201 BROADWAY
Practice Address - Street 2:SUITE 218
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-3773
Practice Address - Country:US
Practice Address - Phone:210-930-8988
Practice Address - Fax:210-930-8986
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25303103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0023CEOtherBCBS
TX00036EMedicare ID - Type Unspecified