Provider Demographics
NPI:1104523042
Name:CORTEZ, DIANIRA RENEE (LPC)
Entity type:Individual
Prefix:
First Name:DIANIRA
Middle Name:RENEE
Last Name:CORTEZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6259 W BLACK BUTTE ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-8704
Mailing Address - Country:US
Mailing Address - Phone:208-991-7873
Mailing Address - Fax:
Practice Address - Street 1:750 W USTICK RD STE 120
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6133
Practice Address - Country:US
Practice Address - Phone:208-991-7378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6104101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health