Provider Demographics
NPI:1831742170
Name:DIAZ, MIGUEL
Entity type:Individual
Prefix:
First Name:MIGUEL
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 1:301 E RUBY ST
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94561-5701
Mailing Address - Country:US
Mailing Address - Phone:925-421-3545
Mailing Address - Fax:
Practice Address - Street 1:144 CONTINENTE AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-1999
Practice Address - Country:US
Practice Address - Phone:925-513-2440
Practice Address - Fax:925-513-2470
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASPA552235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist