Provider Demographics
NPI:1053855379
Name:DIAZ, LIADYS (MASW)
Entity Type:Individual
Prefix:
First Name:LIADYS
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4630 COMMANDER DR APT 1027
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-3512
Mailing Address - Country:US
Mailing Address - Phone:787-394-1051
Mailing Address - Fax:
Practice Address - Street 1:4 SYCAMORE CT APT 102
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708
Practice Address - Country:US
Practice Address - Phone:787-394-1051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD262-521-93-681-0OtherDRIVER LICENSE