Provider Demographics
NPI:1679142087
Name:DIAZ, BERTHA
Entity type:Individual
Prefix:
First Name:BERTHA
Middle Name:
Last Name:DIAZ
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 1:39 YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10607-1345
Mailing Address - Country:US
Mailing Address - Phone:914-882-1928
Mailing Address - Fax:
Practice Address - Street 1:317 NORTH ST
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-2209
Practice Address - Country:US
Practice Address - Phone:914-597-4109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
958OtherPHYSICAL AND EMOTIONAL