Provider Demographics
NPI:1215112123
Name:DIAZ, LOURDES M (LPC, CAC III)
Entity type:Individual
Prefix:PROF
First Name:LOURDES
Middle Name:M
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LPC, CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4603
Mailing Address - Country:US
Mailing Address - Phone:719-526-1418
Mailing Address - Fax:719-526-1205
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4603
Practice Address - Country:US
Practice Address - Phone:719-526-1418
Practice Address - Fax:719-526-1205
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4388101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional