Provider Demographics
NPI:1205386372
Name:DIAZ, MARISA INEZ
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:INEZ
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 1:325 BUENA CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-9679
Mailing Address - Country:US
Mailing Address - Phone:760-754-5500
Mailing Address - Fax:760-566-3569
Practice Address - Street 1:325 BUENA CREEK RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-9679
Practice Address - Country:US
Practice Address - Phone:760-754-5500
Practice Address - Fax:760-566-3569
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73024101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA73024OtherBOARD OF BEHAVIORAL SCIENCES