Provider Demographics
NPI:1538781794
Name:RIVERA DIAZ, PAOLA MARIE
Entity type:Individual
Prefix:
First Name:PAOLA
Middle Name:MARIE
Last Name:RIVERA DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25716 N SANDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85387-6839
Mailing Address - Country:US
Mailing Address - Phone:623-845-2528
Mailing Address - Fax:
Practice Address - Street 1:14780 W MOUNTAIN VIEW BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7280
Practice Address - Country:US
Practice Address - Phone:623-845-2528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker