Provider Demographics
NPI:1386040939
Name:DIAZ, LUIS R (MA, LPC)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:R
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6250 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-3861
Mailing Address - Country:US
Mailing Address - Phone:773-622-6218
Mailing Address - Fax:773-622-7440
Practice Address - Street 1:3166 N LINCOLN AVE
Practice Address - Street 2:STE 224
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3133
Practice Address - Country:US
Practice Address - Phone:773-622-6218
Practice Address - Fax:773-622-7440
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.009609101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional