Provider Demographics
NPI:1235189788
Name:DIAZ GRANADOS, MARY T (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:T
Last Name:DIAZ GRANADOS
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 1:3523 SW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3018
Mailing Address - Country:US
Mailing Address - Phone:786-282-0736
Mailing Address - Fax:305-541-1199
Practice Address - Street 1:2135 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-3319
Practice Address - Country:US
Practice Address - Phone:305-541-4900
Practice Address - Fax:305-541-1199
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0000004103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE1831ZMedicare ID - Type Unspecified