Provider Demographics
NPI:1679624100
Name:DIAZ, DAYNA MV (PHD)
Entity type:Individual
Prefix:DR
First Name:DAYNA
Middle Name:MV
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 1:1770 OLD SPRING HOUSE LN
Mailing Address - Street 2:SUITE 114
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6213
Mailing Address - Country:US
Mailing Address - Phone:770-452-5353
Mailing Address - Fax:770-452-5363
Practice Address - Street 1:1770 OLD SPRING HOUSE LN
Practice Address - Street 2:SUITE 114
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6213
Practice Address - Country:US
Practice Address - Phone:770-452-5353
Practice Address - Fax:770-452-5363
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002970103TC0700X, 103TC2200X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10059861OtherAMERIGROUP PROVIDER NUMBE
GA103882OtherPEACHSTATE CENPATICO