Provider Demographics
NPI:1841630621
Name:DIAZ, RYAN LUIS (AA DEGREE)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:LUIS
Last Name:DIAZ
Suffix:
Gender:M
Credentials:AA DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 RIVERWALK PKWY
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3344
Mailing Address - Country:US
Mailing Address - Phone:951-333-9747
Mailing Address - Fax:
Practice Address - Street 1:4500 RIVERWALK PKWY
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3344
Practice Address - Country:US
Practice Address - Phone:951-333-9747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2014-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst