Provider Demographics
NPI:1871000422
Name:DIAZ, VANESSA (LMFT)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4808 BOSTON HARBOR RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-1843
Mailing Address - Country:US
Mailing Address - Phone:213-292-3899
Mailing Address - Fax:
Practice Address - Street 1:3775 MARTIN WAY E STE A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5007
Practice Address - Country:US
Practice Address - Phone:360-236-7166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103383106H00000X
CAIMF103383106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist