Provider Demographics
NPI:1649474164
Name:DIAZ-BACH, HOLLY
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:
Last Name:DIAZ-BACH
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:PO BOX 1184
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-1184
Mailing Address - Country:US
Mailing Address - Phone:209-505-9216
Mailing Address - Fax:
Practice Address - Street 1:1116 ALICE ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5905
Practice Address - Country:US
Practice Address - Phone:209-578-3132
Practice Address - Fax:209-579-9605
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0000101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YA0404OXOtherADDICTION COUNSELOR