Provider Demographics
NPI:1790571974
Name:DIAZ, MIA NICOLE
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:NICOLE
Last Name:DIAZ
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28245 AVENUE CROCKER STE 220
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1201
Mailing Address - Country:US
Mailing Address - Phone:661-254-7086
Mailing Address - Fax:
Practice Address - Street 1:27602 IRIS PL
Practice Address - Street 2:
Practice Address - City:CASTAIC
Practice Address - State:CA
Practice Address - Zip Code:91384-3786
Practice Address - Country:US
Practice Address - Phone:661-388-1317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician