Provider Demographics
NPI:1821499062
Name:DIAZ, KYRENE
Entity Type:Individual
Prefix:
First Name:KYRENE
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 1:23638 NEWHALL AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-4234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 21ST ST STE R
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-5226
Practice Address - Country:US
Practice Address - Phone:818-275-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 101Y00000X
CA32134103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor