Provider Demographics
NPI:1992125991
Name:DIAZ, DENISE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REIJU
Other - Middle Name:
Other - Last Name:MASSAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 15151
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70895-5151
Mailing Address - Country:US
Mailing Address - Phone:225-371-6475
Mailing Address - Fax:
Practice Address - Street 1:20377 OLD SCENIC HWY
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-7366
Practice Address - Country:US
Practice Address - Phone:225-371-6475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA7655225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
46-4557270OtherLLC