Provider Demographics
NPI:1063045318
Name:DIAZ ESTEBAN, CARLOS A
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:DIAZ ESTEBAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 NW 186TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-3013
Mailing Address - Country:US
Mailing Address - Phone:786-715-2766
Mailing Address - Fax:
Practice Address - Street 1:3080 NW 186TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-3013
Practice Address - Country:US
Practice Address - Phone:786-715-2766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-19-10689106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty