Provider Demographics
NPI:1093176893
Name:RODRIGUEZ, DIANE DIAZ (IMH 14439)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:DIAZ
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:IMH 14439
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 MAITLAND CENTER COMMONS BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7270
Mailing Address - Country:US
Mailing Address - Phone:850-313-6207
Mailing Address - Fax:
Practice Address - Street 1:167 RIDGEMONT CIR SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-2318
Practice Address - Country:US
Practice Address - Phone:850-313-6207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 14439101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health