Provider Demographics
NPI:1205180486
Name:DIAZ, DORIMAR
Entity Type:Individual
Prefix:
First Name:DORIMAR
Middle Name:
Last Name:DIAZ
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 1:110 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-1864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1864
Practice Address - Country:US
Practice Address - Phone:413-304-2917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA042622756OtherCOMMONWEALTH CARE ALLIANCE
MA997303OtherNETWORK HEALTH
MA1303295OtherMBHP
MA12529OtherHEALTH NEW ENGLAND
MA1303295Medicaid
MA71756OtherTUFTS
MA8443OtherBMC/BEACON