Provider Demographics
NPI:1184639569
Name:GONZALEZ-DIAZ, VIVIAN DJ (PHD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:DJ
Last Name:GONZALEZ-DIAZ
Suffix:
Gender:F
Credentials:PHD
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 347604
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33234-7604
Mailing Address - Country:US
Mailing Address - Phone:305-984-8422
Mailing Address - Fax:305-836-4722
Practice Address - Street 1:3271 NW 7TH ST
Practice Address - Street 2:SUITE #203
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-4141
Practice Address - Country:US
Practice Address - Phone:786-220-6902
Practice Address - Fax:866-726-0526
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 171M00000X
FLPY5395103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPY5395OtherPSYCHOLOGIST LICENSE#
FL54114Medicare PIN
FLS30677Medicare UPIN