Provider Demographics
NPI:1235489972
Name:DIAZ, TABITHA
Entity Type:Individual
Prefix:DR
First Name:TABITHA
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 1:225 W BROADWAY STE 155
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1332
Mailing Address - Country:US
Mailing Address - Phone:818-441-7800
Mailing Address - Fax:
Practice Address - Street 1:225 W BROADWAY STE 155
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1332
Practice Address - Country:US
Practice Address - Phone:818-441-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28990103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical