Provider Demographics
NPI:1871151464
Name:MUNOZ, DIEGO (EDS)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:MUNOZ
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25775 W IL ROUTE 134
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60041-9587
Mailing Address - Country:US
Mailing Address - Phone:630-550-7694
Mailing Address - Fax:
Practice Address - Street 1:25775 W IL ROUTE 134
Practice Address - Street 2:
Practice Address - City:INGLESIDE
Practice Address - State:IL
Practice Address - Zip Code:60041-9587
Practice Address - Country:US
Practice Address - Phone:630-550-7694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2537959103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool