Provider Demographics
NPI:1851660914
Name:DIAZ, AGNES S (PHD)
Entity type:Individual
Prefix:DR
First Name:AGNES
Middle Name:S
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:AF24 CALLE 31
Mailing Address - Street 2:URB. INTERAMERICANA
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-3411
Mailing Address - Country:US
Mailing Address - Phone:787-550-9708
Mailing Address - Fax:
Practice Address - Street 1:788 AVE SAN PATRICIO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-1303
Practice Address - Country:US
Practice Address - Phone:787-550-9708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
PR4105103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist