Provider Demographics
NPI:1205562402
Name:DIAZ, ROSSANA (LE, CMT, MMP)
Entity type:Individual
Prefix:
First Name:ROSSANA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LE, CMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 E 9TH ST APT 10
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-8108
Mailing Address - Country:US
Mailing Address - Phone:626-905-6330
Mailing Address - Fax:
Practice Address - Street 1:222 N MOUNTAIN AVE STE 210A
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5714
Practice Address - Country:US
Practice Address - Phone:833-473-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88703225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist