Provider Demographics
NPI:1518217355
Name:DIAZ, BRITTANY NICOLE
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:NICOLE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:
Other - Last Name:ALONZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2009 MERMAID DR.
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936
Mailing Address - Country:US
Mailing Address - Phone:915-637-1676
Mailing Address - Fax:
Practice Address - Street 1:21045 N 9TH PL STE 204
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-5635
Practice Address - Country:US
Practice Address - Phone:602-726-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117679225X00000X
TX37126235Z00000X
AZ009441225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ189296Medicaid
TX207164901Medicaid
TX149984001Medicaid
TX207164901Medicaid