Provider Demographics
NPI:1730663311
Name:DIAZ MOGOLLON, EUGENIA MARIA
Entity Type:Individual
Prefix:
First Name:EUGENIA
Middle Name:MARIA
Last Name:DIAZ MOGOLLON
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 1:3498 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:RESCUE
Mailing Address - State:CA
Mailing Address - Zip Code:95672-9625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3498 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:RESCUE
Practice Address - State:CA
Practice Address - Zip Code:95672-9625
Practice Address - Country:US
Practice Address - Phone:530-391-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55852355S0801X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5585OtherSPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY AND HEARING AID DISPENSERS BOARD