Provider Demographics
NPI:1679972970
Name:DIAMOND, MORTAKAI
Entity Type:Individual
Prefix:
First Name:MORTAKAI
Middle Name:
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 59TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1417
Mailing Address - Country:US
Mailing Address - Phone:323-742-6031
Mailing Address - Fax:
Practice Address - Street 1:727 59TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1417
Practice Address - Country:US
Practice Address - Phone:323-742-6031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANONE1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390200000XOtherBERKELEY MENTAL HEALTH