Provider Demographics
NPI:1568079408
Name:DIAZ, ALEJANDRA T
Entity Type:Individual
Prefix:
First Name:ALEJANDRA
Middle Name:T
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 1:11046 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-2617
Mailing Address - Country:US
Mailing Address - Phone:626-444-9000
Mailing Address - Fax:
Practice Address - Street 1:11519 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249
Practice Address - Country:US
Practice Address - Phone:310-679-9126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1360810819101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)