Provider Demographics
NPI:1518155324
Name:DIAZ, SAN JUANITA (MS, LPC)
Entity Type:Individual
Prefix:
First Name:SAN JUANITA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 W AVENUE J
Mailing Address - Street 2:
Mailing Address - City:ROBSTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78380-2511
Mailing Address - Country:US
Mailing Address - Phone:361-737-1076
Mailing Address - Fax:
Practice Address - Street 1:5151 FLYNN PKWY
Practice Address - Street 2:SUITE 114
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4318
Practice Address - Country:US
Practice Address - Phone:361-884-7600
Practice Address - Fax:361-884-7677
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19768101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health