Provider Demographics
NPI:1841802949
Name:DIAZ, BIANCA DE JESUS
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:DE JESUS
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 1:130 HARDENBURGH AVE
Mailing Address - Street 2:
Mailing Address - City:DEMAREST
Mailing Address - State:NJ
Mailing Address - Zip Code:07627-2159
Mailing Address - Country:US
Mailing Address - Phone:917-434-0768
Mailing Address - Fax:
Practice Address - Street 1:130 HARDENBURGH AVE
Practice Address - Street 2:
Practice Address - City:DEMAREST
Practice Address - State:NJ
Practice Address - Zip Code:07627-2159
Practice Address - Country:US
Practice Address - Phone:917-434-0768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool