Provider Demographics
NPI:1396982815
Name:DIAZ, VICTOR (LCSW)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 380156
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02238-0156
Mailing Address - Country:US
Mailing Address - Phone:617-666-8606
Mailing Address - Fax:
Practice Address - Street 1:61 MEDFORD ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3421
Practice Address - Country:US
Practice Address - Phone:617-629-3919
Practice Address - Fax:617-629-4644
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2153631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical