Provider Demographics
NPI:1447735667
Name:DIAZ, MAGUEN LANDA-SAMANO
Entity Type:Individual
Prefix:
First Name:MAGUEN
Middle Name:LANDA-SAMANO
Last Name:DIAZ
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 1:220 GERMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-9605
Mailing Address - Country:US
Mailing Address - Phone:509-832-3124
Mailing Address - Fax:
Practice Address - Street 1:220 GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-9605
Practice Address - Country:US
Practice Address - Phone:509-832-3124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60834054101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60834054OtherWASHINGTON STATE DEPARTMENT OF HEALTH