Provider Demographics
NPI:1316257983
Name:DIAZ, JOSE L
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:L
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 1:3700 JOSEPH SIEWICK DR STE 408A
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1745
Mailing Address - Country:US
Mailing Address - Phone:703-391-3300
Mailing Address - Fax:703-391-4380
Practice Address - Street 1:3700 JOSEPH SIEWICK DR STE 408A
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1745
Practice Address - Country:US
Practice Address - Phone:703-391-3300
Practice Address - Fax:703-391-4380
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 10445101YM0800X
VA0701007329101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health