Provider Demographics
NPI:1659651115
Name:DIAZ, GINA MARIE (LMHC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10850 NW 105TH CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IA
Mailing Address - Zip Code:50109-9630
Mailing Address - Country:US
Mailing Address - Phone:515-491-8522
Mailing Address - Fax:
Practice Address - Street 1:10850 NW 105TH CT
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IA
Practice Address - Zip Code:50109-9630
Practice Address - Country:US
Practice Address - Phone:515-491-8522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA350101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA183447000Medicaid