Provider Demographics
NPI:1538637756
Name:DIEGO, CASEY J
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:J
Last Name:DIEGO
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 1:55 W 39TH ST RM 301
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-0569
Mailing Address - Country:US
Mailing Address - Phone:516-287-4009
Mailing Address - Fax:
Practice Address - Street 1:55 W 39TH ST RM 301
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-0569
Practice Address - Country:US
Practice Address - Phone:516-287-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008623101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health