Provider Demographics
NPI:1164222105
Name:DIAZ, GABRIELLA (BSN, LAPC)
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:BSN, LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 HIGHWAY 54 W STE 100
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4760
Mailing Address - Country:US
Mailing Address - Phone:770-742-0790
Mailing Address - Fax:
Practice Address - Street 1:6 EASTWOOD CT
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1305
Practice Address - Country:US
Practice Address - Phone:315-408-7595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC010095101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor