Provider Demographics
NPI:1194378679
Name:GODOY DIAZ, ALBA LUISA (RBT)
Entity Type:Individual
Prefix:
First Name:ALBA
Middle Name:LUISA
Last Name:GODOY DIAZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PINTAIL CT
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-2912
Mailing Address - Country:US
Mailing Address - Phone:786-486-3236
Mailing Address - Fax:
Practice Address - Street 1:1224 US 1 STE H
Practice Address - Street 2:
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-3539
Practice Address - Country:US
Practice Address - Phone:561-203-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2022-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-80986106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103949200Medicaid