Provider Demographics
NPI:1609626449
Name:DIAZ, SUZANNE TELLEZ (LCSW)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:TELLEZ
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-0790
Mailing Address - Country:US
Mailing Address - Phone:928-433-3732
Mailing Address - Fax:
Practice Address - Street 1:463 S LAKE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0856
Practice Address - Country:US
Practice Address - Phone:928-645-5113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ220521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ22052OtherLCSW LICENSE