Provider Demographics
NPI:1326805938
Name:DIEGO, ITZEL
Entity Type:Individual
Prefix:
First Name:ITZEL
Middle Name:
Last Name:DIEGO
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 1:1121 JUDSON RD STE 140
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5119
Mailing Address - Country:US
Mailing Address - Phone:903-309-0702
Mailing Address - Fax:
Practice Address - Street 1:1121 JUDSON RD STE 140
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5119
Practice Address - Country:US
Practice Address - Phone:903-309-0702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110207104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker