Provider Demographics
NPI:1376285221
Name:DIAZ, MARIAH AMANDA
Entity type:Individual
Prefix:MS
First Name:MARIAH
Middle Name:AMANDA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 CABRILLO PARK DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-5017
Mailing Address - Country:US
Mailing Address - Phone:714-953-4455
Mailing Address - Fax:
Practice Address - Street 1:600 W SANTA ANA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4558
Practice Address - Country:US
Practice Address - Phone:714-953-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT139292106H00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist