Provider Demographics
NPI:1275744674
Name:DIAZ, AUDREA A
Entity Type:Individual
Prefix:
First Name:AUDREA
Middle Name:A
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:PO BOX 7369
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-0369
Mailing Address - Country:US
Mailing Address - Phone:909-335-7067
Mailing Address - Fax:909-792-2045
Practice Address - Street 1:1323 W COLTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2853
Practice Address - Country:US
Practice Address - Phone:909-335-7067
Practice Address - Fax:909-792-2045
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW0772101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4739OtherSIMON STAFF NUMBER