Provider Demographics
NPI:1578156691
Name:RODRIGUEZ, DIANA (LAC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 S MILL AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7734
Mailing Address - Country:US
Mailing Address - Phone:844-949-3989
Mailing Address - Fax:
Practice Address - Street 1:4820 S MILL AVE STE 203
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7734
Practice Address - Country:US
Practice Address - Phone:844-949-3989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-18082101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health