Provider Demographics
NPI:1063224384
Name:DIAZ, GINA (MPSY)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MPSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:VILLA GUADALUPE
Mailing Address - Street 2:FF14 CALLE 18
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-4055
Mailing Address - Country:US
Mailing Address - Phone:787-347-7698
Mailing Address - Fax:
Practice Address - Street 1:155 CALLE ANDRES ARUS RIVERA W
Practice Address - Street 2:
Practice Address - City:GURABO
Practice Address - State:PR
Practice Address - Zip Code:00778-2321
Practice Address - Country:US
Practice Address - Phone:939-891-0533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7343103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty