Provider Demographics
NPI:1679952303
Name:DIAZ, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
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 1:1520 NICE AVE
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-2831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1520 NICE AVE
Practice Address - Street 2:
Practice Address - City:GROVER BEACH
Practice Address - State:CA
Practice Address - Zip Code:93433-2831
Practice Address - Country:US
Practice Address - Phone:805-944-4612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD1408301054101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)