Provider Demographics
NPI:1407979578
Name:DIAMOND, GUS TOM
Entity Type:Individual
Prefix:MR
First Name:GUS
Middle Name:TOM
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:GUS
Other - Middle Name:T
Other - Last Name:DIAMOND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:3134 N 80TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-9765
Mailing Address - Country:US
Mailing Address - Phone:602-478-9831
Mailing Address - Fax:
Practice Address - Street 1:2500 S POWER RD STE 108
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-6687
Practice Address - Country:US
Practice Address - Phone:480-981-6089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-10267101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health