Provider Demographics
NPI:1295144699
Name:DIAZ, CHARISSE RENEE (LMHC)
Entity type:Individual
Prefix:
First Name:CHARISSE
Middle Name:RENEE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 ALTERNATE 19 NORTH
Mailing Address - Street 2:SUITE 507-6
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683
Mailing Address - Country:US
Mailing Address - Phone:813-601-0595
Mailing Address - Fax:
Practice Address - Street 1:2708 ALTERNATE 19 NORTH
Practice Address - Street 2:SUITE 507-6
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683
Practice Address - Country:US
Practice Address - Phone:813-601-0595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13291101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health