Provider Demographics
NPI:1346354891
Name:DIAZ, SUSAN MIQUELA (PH D)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MIQUELA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:MIQUELA
Other - Middle Name:
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:185 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JORDANVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13361-2729
Mailing Address - Country:US
Mailing Address - Phone:315-360-0527
Mailing Address - Fax:607-204-4120
Practice Address - Street 1:1676 SUNSET AVE FL 3
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5416
Practice Address - Country:US
Practice Address - Phone:315-360-0527
Practice Address - Fax:607-204-4120
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016342101YP2500X
NY016342-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional