Provider Demographics
NPI:1235781873
Name:DIAZ-ORTIZ, LESLIE MICHELLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:MICHELLE
Last Name:DIAZ-ORTIZ
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 1:10419 NW 82ND ST UNIT 4
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4093
Mailing Address - Country:US
Mailing Address - Phone:787-299-6873
Mailing Address - Fax:
Practice Address - Street 1:8890 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-7235
Practice Address - Country:US
Practice Address - Phone:954-742-7032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103G00000X
FLPY10504103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist