Provider Demographics
NPI:1477756690
Name:DIAZ, BRENDA MARIA (MS, MFT INTERN)
Entity Type:Individual
Prefix:MISS
First Name:BRENDA
Middle Name:MARIA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MS, MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 N GRAND AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-1551
Mailing Address - Country:US
Mailing Address - Phone:619-436-8268
Mailing Address - Fax:
Practice Address - Street 1:1126 N GRAND AVE
Practice Address - Street 2:SUITE D
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1551
Practice Address - Country:US
Practice Address - Phone:619-436-8268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT99479106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist