Provider Demographics
NPI:1629588017
Name:DIAZ, THALIA (MA)
Entity Type:Individual
Prefix:
First Name:THALIA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7516
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85246-7516
Mailing Address - Country:US
Mailing Address - Phone:480-420-6741
Mailing Address - Fax:
Practice Address - Street 1:555 S GALLERIA WAY UNIT 397
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-1544
Practice Address - Country:US
Practice Address - Phone:480-420-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9659101YP2500X
106H00000X
CA122000106H00000X
AZLMFT-15769106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional