Provider Demographics
NPI:1275333015
Name:DIAZ, MILDRED
Entity type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:
Last Name:DIAZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 W 129TH ST APT 11B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-1924
Mailing Address - Country:US
Mailing Address - Phone:347-326-2666
Mailing Address - Fax:347-326-2666
Practice Address - Street 1:3708 91ST ST STE 3A
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7962
Practice Address - Country:US
Practice Address - Phone:718-779-2263
Practice Address - Fax:718-779-2225
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-18
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker