Provider Demographics
NPI:1043869175
Name:DIAZ, STEPHANIE (RBT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6721 NW 192ND LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-2451
Mailing Address - Country:US
Mailing Address - Phone:786-514-5335
Mailing Address - Fax:
Practice Address - Street 1:11441 INTERCHANGE CIR S
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-6009
Practice Address - Country:US
Practice Address - Phone:305-573-6333
Practice Address - Fax:305-573-6888
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB508346106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD200780965240Medicaid