Provider Demographics
NPI:1043888159
Name:DIAZ, SUSANA M (ASW)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:M
Last Name:DIAZ
Suffix:
Gender:
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 RICHLAND AVE BLDG D
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-4562
Mailing Address - Country:US
Mailing Address - Phone:209-525-5715
Mailing Address - Fax:
Practice Address - Street 1:1904 RICHLAND AVE BLDG D
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-4562
Practice Address - Country:US
Practice Address - Phone:209-525-5715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93103101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional