Provider Demographics
NPI:1144536939
Name:DIAZ, AMANDA J (LCSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:POLIZZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2450 W RIDGE RD STE 304A
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-3037
Mailing Address - Country:US
Mailing Address - Phone:315-975-9450
Mailing Address - Fax:
Practice Address - Street 1:2450 W RIDGE RD STE 304A
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-3037
Practice Address - Country:US
Practice Address - Phone:315-975-9450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YA0400X
NY098993-1104100000X
1041C0700X
NY094633-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid