Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | ||
N | 101YM0800X | Mental Health Counselor | ||
N | 101YP1600X | Pastoral Counselor |
NPI | 1053953430 |
---|---|
Provider Name | Juventino Diez |
First Address | Bronx, NY 10473-2499 |
Second Address | Bronx, NY 10473-2499 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/10/2019 |
Last Update Date | 17/10/2019 |