Provider Demographics
NPI:1992357180
Name:DIAZ, MARYLOU MORALES (MSW)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:MORALES
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1510
Mailing Address - Country:US
Mailing Address - Phone:509-838-4651
Mailing Address - Fax:509-363-2762
Practice Address - Street 1:131 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1510
Practice Address - Country:US
Practice Address - Phone:509-838-4651
Practice Address - Fax:509-363-2762
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60658225390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program