Provider Demographics
NPI:1700465507
Name:DIAZ, DANIEL RAUL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAUL
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 1:820 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0928
Mailing Address - Country:US
Mailing Address - Phone:909-387-7757
Mailing Address - Fax:909-387-7757
Practice Address - Street 1:820 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-2316
Practice Address - Country:US
Practice Address - Phone:909-386-8510
Practice Address - Fax:909-387-7757
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10956101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8048Medicaid