Basic Information
| Provider Information | |||||||||
| NPI: | 1073109005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 313 HAWTHORNE AVE | ||||||||
| Address2: | |||||||||
| City: | BENSENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601062337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303960753 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 ROHLWING RD | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE VLG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475248800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2020 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.