Provider Demographics
NPI:1568724334
Name:DIAZ, KATELYN (MSED)
Entity Type:Individual
Prefix:MS
First Name:KATELYN
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 W 239TH ST
Mailing Address - Street 2:3E
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1234
Mailing Address - Country:US
Mailing Address - Phone:718-578-7019
Mailing Address - Fax:
Practice Address - Street 1:1301 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-3119
Practice Address - Country:US
Practice Address - Phone:212-426-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1676482252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency