Provider Demographics
NPI:1114168655
Name:DIAZ, BRENDA (MS, OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:BRENDA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8930 SW 198TH TER
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-8970
Mailing Address - Country:US
Mailing Address - Phone:305-495-8065
Mailing Address - Fax:
Practice Address - Street 1:8930 SW 198TH TER
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-8970
Practice Address - Country:US
Practice Address - Phone:305-495-8065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9412225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886734800Medicaid