Provider Demographics
NPI:1871326066
Name:DIAZ, SUMMER MADISON (MS, BCBA)
Entity type:Individual
Prefix:
First Name:SUMMER
Middle Name:MADISON
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5435 BALBOA BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1570
Mailing Address - Country:US
Mailing Address - Phone:310-351-0354
Mailing Address - Fax:310-933-4134
Practice Address - Street 1:5435 BALBOA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1570
Practice Address - Country:US
Practice Address - Phone:310-933-4499
Practice Address - Fax:310-933-4134
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-24-75126103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst