Provider Demographics
NPI:1962421834
Name:DIAZ, CARMEN MARGARITA (PHD)
Entity type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:MARGARITA
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 1:3831 E. LOHMAN AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011
Mailing Address - Country:US
Mailing Address - Phone:575-522-5802
Mailing Address - Fax:866-284-6720
Practice Address - Street 1:3831 E. LOHMAN AVE
Practice Address - Street 2:STE 202
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:575-522-5802
Practice Address - Fax:866-284-6720
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM0912103T00000X
NM0912103TP0016X
NM0032103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM62125729Medicaid
NM00679577Medicaid