Provider Demographics
NPI:1689337073
Name:DIAZ, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
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 1:8511 DAVIS LAKE PKWY STE C6228
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-0536
Mailing Address - Country:US
Mailing Address - Phone:323-695-9067
Mailing Address - Fax:
Practice Address - Street 1:8511 DAVIS LAKE PKWY STE C6228
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-0536
Practice Address - Country:US
Practice Address - Phone:323-695-9067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16336101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health