Provider Demographics
NPI:1982196713
Name:TELLEZ, DIANA MARITZA (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:MARITZA
Last Name:TELLEZ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 S 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-4026
Mailing Address - Country:US
Mailing Address - Phone:509-831-6332
Mailing Address - Fax:
Practice Address - Street 1:2811 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3761
Practice Address - Country:US
Practice Address - Phone:509-426-1903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW604967711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical