Provider Demographics
NPI:1871845370
Name:DIAZ, ELIAS
Entity Type:Individual
Prefix:
First Name:ELIAS
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 1:2033 FOX BOROUGH
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852
Mailing Address - Country:US
Mailing Address - Phone:310-414-7799
Mailing Address - Fax:
Practice Address - Street 1:1200 WILSHIRE BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1908
Practice Address - Country:US
Practice Address - Phone:213-481-1347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
202899106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist