Provider Demographics
NPI:1629819420
Name:DIAZ, ANGELICA
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
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 1:11201 5TH ST APT B107
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5953
Mailing Address - Country:US
Mailing Address - Phone:951-988-4319
Mailing Address - Fax:
Practice Address - Street 1:21241 VENTURA BLVD STE 187
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2196
Practice Address - Country:US
Practice Address - Phone:818-203-5063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist