Provider Demographics
NPI:1003465295
Name:ADORNO DIAZ, MARIEL (MA)
Entity type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:ADORNO DIAZ
Suffix:
Gender:F
Credentials:MA
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 1608
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00613-1608
Mailing Address - Country:US
Mailing Address - Phone:787-956-0062
Mailing Address - Fax:
Practice Address - Street 1:CARR 10 R 651 KM 2.4
Practice Address - Street 2:SEC EL JUNCO, BO. JUNCOS
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-0000
Practice Address - Country:US
Practice Address - Phone:787-214-9887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6013103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR039487800Medicaid