Provider Demographics
NPI:1851670046
Name:DIAZ, SAMUEL (MS)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WADSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-7108
Mailing Address - Country:US
Mailing Address - Phone:860-527-1124
Mailing Address - Fax:860-724-2539
Practice Address - Street 1:45 WARDSWORTH ST.
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106
Practice Address - Country:US
Practice Address - Phone:860-527-1124
Practice Address - Fax:860-724-2539
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)