Provider Demographics
NPI:1235917865
Name:DIAZ MASSIP, JUAN CARLOS
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:DIAZ MASSIP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 NW 19TH TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-3913
Mailing Address - Country:US
Mailing Address - Phone:239-645-1116
Mailing Address - Fax:
Practice Address - Street 1:1591 HAYLEY LN STE 101
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2121
Practice Address - Country:US
Practice Address - Phone:239-288-6046
Practice Address - Fax:888-388-5055
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty