Provider Demographics
NPI:1124718127
Name:DIAZ, ERIBERTO GUADALUPE
Entity type:Individual
Prefix:
First Name:ERIBERTO
Middle Name:GUADALUPE
Last Name:DIAZ
Suffix:
Gender:M
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 366
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0366
Mailing Address - Country:US
Mailing Address - Phone:509-865-5233
Mailing Address - Fax:509-865-6505
Practice Address - Street 1:321 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-1527
Practice Address - Country:US
Practice Address - Phone:509-865-5233
Practice Address - Fax:509-865-6505
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61417062101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)