Provider Demographics
NPI:1033947973
Name:DIAZ, NICHOLE B (CSW, BT)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:B
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CSW, BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9005 EL OJITO CT NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5968
Mailing Address - Country:US
Mailing Address - Phone:505-322-0237
Mailing Address - Fax:
Practice Address - Street 1:500 UNSER BLVD SE STE 103
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4660
Practice Address - Country:US
Practice Address - Phone:505-623-9814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN0015917Medicaid