Provider Demographics
NPI:1710424791
Name:DIAZ, VIVIAN ROSE (CAS I)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:ROSE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CAS I
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:ROSE
Other - Last Name:MENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAS I
Mailing Address - Street 1:3520 E SHIELDS AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-6923
Mailing Address - Country:US
Mailing Address - Phone:559-538-1230
Mailing Address - Fax:844-609-2973
Practice Address - Street 1:1553 SANTA CLARA ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-3447
Practice Address - Country:US
Practice Address - Phone:559-538-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-27
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes172V00000XOther Service ProvidersCommunity Health Worker