Provider Demographics
NPI:1326892647
Name:DIAZ, LAURA (MA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 ACADIA DR
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-3341
Mailing Address - Country:US
Mailing Address - Phone:512-387-6822
Mailing Address - Fax:
Practice Address - Street 1:2208 E 14TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-1306
Practice Address - Country:US
Practice Address - Phone:512-387-6822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205079106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist