Provider Demographics
NPI:1922145374
Name:DIAZ, CARLO (MFT)
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 S OAK KNOLL AVE APT 206
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2625
Mailing Address - Country:US
Mailing Address - Phone:626-818-6511
Mailing Address - Fax:
Practice Address - Street 1:1515 HOPE ST # 202
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2610
Practice Address - Country:US
Practice Address - Phone:626-344-8212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 47772106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist