Provider Demographics
NPI:1114503521
Name:RIVERA DIAZ, NIURYS
Entity Type:Individual
Prefix:
First Name:NIURYS
Middle Name:
Last Name:RIVERA DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 SW 55TH ST UNIT 88
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3105
Mailing Address - Country:US
Mailing Address - Phone:786-716-9222
Mailing Address - Fax:
Practice Address - Street 1:11201 SW 55TH ST UNIT 88
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-3105
Practice Address - Country:US
Practice Address - Phone:786-716-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-126033106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty