Provider Demographics
NPI:1588802417
Name:DIAZ, MANUELA ANA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MANUELA
Middle Name:ANA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2927A SHATTUCK AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1808
Mailing Address - Country:US
Mailing Address - Phone:510-358-1967
Mailing Address - Fax:510-217-2296
Practice Address - Street 1:2927A SHATTUCK AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1808
Practice Address - Country:US
Practice Address - Phone:510-358-1967
Practice Address - Fax:510-217-2216
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22309103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22309OtherPSYCHOLOGY LICENSE