Provider Demographics
NPI:1245720366
Name:DIAZ, GERARDO JOSE (AMFT# 136318)
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:JOSE
Last Name:DIAZ
Suffix:
Gender:M
Credentials:AMFT# 136318
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-4023
Mailing Address - Country:US
Mailing Address - Phone:530-662-2211
Mailing Address - Fax:530-758-8490
Practice Address - Street 1:455 1ST ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-4023
Practice Address - Country:US
Practice Address - Phone:530-662-2211
Practice Address - Fax:530-758-8490
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 106S00000X
CA136318106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician