Provider Demographics
NPI:1821805581
Name:DIAZ, ITZEL
Entity type:Individual
Prefix:
First Name:ITZEL
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 1:1454 W BLACKHAWK ST APT G
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-8135
Mailing Address - Country:US
Mailing Address - Phone:812-679-8552
Mailing Address - Fax:
Practice Address - Street 1:1454 W BLACKHAWK ST APT G
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-8135
Practice Address - Country:US
Practice Address - Phone:812-679-8552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.1142661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical