Provider Demographics
NPI:1093764060
Name:DIETSCH-VAZQUEZ, LILIANA (MED, OTR/L, BCBA)
Entity Type:Individual
Prefix:
First Name:LILIANA
Middle Name:
Last Name:DIETSCH-VAZQUEZ
Suffix:
Gender:F
Credentials:MED, OTR/L, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 297883
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-7883
Mailing Address - Country:US
Mailing Address - Phone:954-249-0773
Mailing Address - Fax:954-391-8176
Practice Address - Street 1:8200 NW 41ST ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6205
Practice Address - Country:US
Practice Address - Phone:786-774-7729
Practice Address - Fax:954-391-8176
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11239225X00000X
FLBACB 1-08-4716103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889475200Medicaid