Provider Demographics
NPI:1861273658
Name:DIAZ, MIA MONIQUE
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:MONIQUE
Last Name: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 1:38725 N HILLTOP AVE
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-9632
Mailing Address - Country:US
Mailing Address - Phone:815-751-3527
Mailing Address - Fax:
Practice Address - Street 1:38725 N HILLTOP AVE
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-9632
Practice Address - Country:US
Practice Address - Phone:815-751-3527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach