Provider Demographics
NPI:1275311904
Name:DIAZ OLIVERA, JUAN CARLOS (CADC-1)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:DIAZ OLIVERA
Suffix:
Gender:M
Credentials:CADC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 SE D ST
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-1619
Mailing Address - Country:US
Mailing Address - Phone:541-233-9125
Mailing Address - Fax:
Practice Address - Street 1:236 SE D ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1619
Practice Address - Country:US
Practice Address - Phone:541-233-9125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-08-10841101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)