Provider Demographics
NPI:1225536519
Name:CENTENO-DIAZ, IDALIA (LICSW)
Entity Type:Individual
Prefix:
First Name:IDALIA
Middle Name:
Last Name:CENTENO-DIAZ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 MAIN ST FL 400
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-1063
Mailing Address - Country:US
Mailing Address - Phone:413-739-5572
Mailing Address - Fax:
Practice Address - Street 1:1695 MAIN ST FL 4
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1348
Practice Address - Country:US
Practice Address - Phone:413-787-5572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7597104100000X
CT125131041C0700X
MA1253021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker