Provider Demographics
NPI:1942333687
Name:DIAZ, PAMELA DENICE (LMSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DENICE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:310 N. OAK ST.
Practice Address - Street 2:
Practice Address - City:BROOKLAND
Practice Address - State:AR
Practice Address - Zip Code:72417
Practice Address - Country:US
Practice Address - Phone:870-932-2080
Practice Address - Fax:870-974-9762
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AR3757-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1722884795Medicaid