Provider Demographics
NPI:1063700151
Name:AVALOS, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:AVALOS
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 10501
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95157-1501
Mailing Address - Country:US
Mailing Address - Phone:714-717-2963
Mailing Address - Fax:
Practice Address - Street 1:500 ALLERTON ST
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-1519
Practice Address - Country:US
Practice Address - Phone:650-599-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-A1004152144324500000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility