Provider Demographics
NPI:1801977921
Name:DIAZ, SANDRA HALL (LCSW)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:HALL
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W. PORTER AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564
Mailing Address - Country:US
Mailing Address - Phone:228-872-2011
Mailing Address - Fax:228-872-3791
Practice Address - Street 1:310 W. PORTER AVE
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564
Practice Address - Country:US
Practice Address - Phone:228-872-2011
Practice Address - Fax:228-872-3791
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC1885101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0118148Medicaid
MS62-51970OtherMAIL HANDLERS BENEFIT PLA
NYSWL-3703000OtherAMERICAN PROFESSIONAL AGE
MSC1885OtherMS STATE LICENSE
MS800000075Medicare ID - Type Unspecified