Provider Demographics
NPI:1447035779
Name:DIAZ, LUIS A SR
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:A
Last Name:DIAZ
Suffix:SR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:LUIS
Other - Middle Name:A
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LDAC
Mailing Address - Street 1:19 VINSON ST , #3
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:774-441-4501
Mailing Address - Fax:
Practice Address - Street 1:90 MADISON ST STE 502
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-2058
Practice Address - Country:US
Practice Address - Phone:774-530-6363
Practice Address - Fax:774-530-6364
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)