Provider Demographics
NPI:1235891185
Name:DIAZ-MENENDEZ, DIARISLEIDYS
Entity Type:Individual
Prefix:
First Name:DIARISLEIDYS
Middle Name:
Last Name:DIAZ-MENENDEZ
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 1:6646 SW 115TH CT APT 119
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-4799
Mailing Address - Country:US
Mailing Address - Phone:305-721-7217
Mailing Address - Fax:
Practice Address - Street 1:6646 SW 115TH CT APT 119
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-4799
Practice Address - Country:US
Practice Address - Phone:305-721-7217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-134518106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician