Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor | 0129351 | NM |
NPI | 1003130279 |
---|---|
Provider Name | Jessica Diaz |
First Address | Albuquerque, NM 87109-3179 |
Second Address | Albuquerque, NM 87109-3179 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2010 |
Last Update Date | 17/03/2010 |