Provider Demographics
NPI:1619672045
Name:DIAZ, KATRINA LUPE
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:LUPE
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 1:37188 MELROSE DR APT 1
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-7755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44359 PALM ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3116
Practice Address - Country:US
Practice Address - Phone:760-342-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor