Provider Demographics
NPI:1821610650
Name:DIAZ, ALEJANDRO
Entity Type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:
Last Name:DIAZ
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 1:900 IROLO ST APT 218
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-6413
Mailing Address - Country:US
Mailing Address - Phone:602-849-5055
Mailing Address - Fax:
Practice Address - Street 1:18646 OXNARD ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1411
Practice Address - Country:US
Practice Address - Phone:818-654-3908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
106E00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA116020295Medicaid