Provider Demographics
NPI:1194445262
Name:DIAZ, GISELE KIANA (APCC)
Entity type:Individual
Prefix:
First Name:GISELE
Middle Name:KIANA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:KIANA
Other - Middle Name:
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5348 UNIVERSITY AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-8025
Mailing Address - Country:US
Mailing Address - Phone:619-255-9278
Mailing Address - Fax:
Practice Address - Street 1:5348 UNIVERSITY AVE STE 108
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-8025
Practice Address - Country:US
Practice Address - Phone:619-255-9278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC14775101YP2500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7162086Medicaid