Provider Demographics
NPI:1336653351
Name:DIAZ, IRAIDA I
Entity Type:Individual
Prefix:
First Name:IRAIDA
Middle Name:I
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 1:637 SW 3RD ST APT 304
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-2314
Mailing Address - Country:US
Mailing Address - Phone:786-253-9324
Mailing Address - Fax:786-502-8968
Practice Address - Street 1:6421 SW 43RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-5134
Practice Address - Country:US
Practice Address - Phone:786-253-9324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-140341106S00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253Z00000XOtherTAXONOMY