Provider Demographics
NPI:1316540438
Name:DIAZ, AMANDA DORIS
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DORIS
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 1:207 LESLIE CT
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-5535
Mailing Address - Country:US
Mailing Address - Phone:646-510-5520
Mailing Address - Fax:
Practice Address - Street 1:207 LESLIE CT
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-5535
Practice Address - Country:US
Practice Address - Phone:646-510-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2203000840235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist