Provider Demographics
NPI:1396914248
Name:DIAZ, HORACIO
Entity type:Individual
Prefix:
First Name:HORACIO
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3064 S ADRIENNE DR
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-2103
Mailing Address - Country:US
Mailing Address - Phone:626-965-0708
Mailing Address - Fax:562-490-7601
Practice Address - Street 1:5150 E PCH STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3394
Practice Address - Country:US
Practice Address - Phone:562-490-7600
Practice Address - Fax:562-490-7601
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF82081106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist