Provider Demographics
NPI:1275942328
Name:DIAZ, DANIELLE
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
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 1:345 N VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-1134
Mailing Address - Country:US
Mailing Address - Phone:516-368-5943
Mailing Address - Fax:
Practice Address - Street 1:345 N VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-1134
Practice Address - Country:US
Practice Address - Phone:516-368-5943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-02
Last Update Date:2014-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY682051116103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst