Provider Demographics
NPI:1326632548
Name:DIAZ, YESENIA C
Entity Type:Individual
Prefix:
First Name:YESENIA
Middle Name:C
Last Name:DIAZ
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 1:1011 MALAGA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-8017
Mailing Address - Country:US
Mailing Address - Phone:321-278-0646
Mailing Address - Fax:
Practice Address - Street 1:1011 MALAGA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8017
Practice Address - Country:US
Practice Address - Phone:321-278-0646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-28
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-136001106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician