Provider Demographics
NPI:1982161691
Name:DIAZ, JAVIER A JR
Entity Type:Individual
Prefix:MR
First Name:JAVIER
Middle Name:A
Last Name:DIAZ
Suffix:JR
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 1:13937 CUYAMACA RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-5904
Mailing Address - Country:US
Mailing Address - Phone:951-463-3419
Mailing Address - Fax:
Practice Address - Street 1:222 E MAIN ST STE 117
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2365
Practice Address - Country:US
Practice Address - Phone:951-463-3419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician