Provider Demographics
NPI:1891847752
Name:DIAZ, PETRA (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETRA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78540-1950
Mailing Address - Country:US
Mailing Address - Phone:956-624-6755
Mailing Address - Fax:956-380-2971
Practice Address - Street 1:2602 SAN GABRIEL ST
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-6951
Practice Address - Country:US
Practice Address - Phone:956-624-6755
Practice Address - Fax:956-380-2971
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-2964103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX31879479Medicaid
TX000000N41NOtherPSYCHOLOGIST
TX000000N41NOtherPSYCHOLOGIST