Provider Demographics
NPI:1053958801
Name:ANZALDUA, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:ANZALDUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 RAMBLE LN STE 120
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-2281
Mailing Address - Country:US
Mailing Address - Phone:512-270-8215
Mailing Address - Fax:
Practice Address - Street 1:111 RAMBLE LN STE 120
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-2281
Practice Address - Country:US
Practice Address - Phone:512-270-8215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64519104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker