Provider Demographics
NPI:1376394973
Name:DIAZ GUTIERREZ, LEIDY
Entity Type:Individual
Prefix:
First Name:LEIDY
Middle Name:
Last Name:DIAZ GUTIERREZ
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 1:104 LEELAND HEIGHTS BLVD W
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-6740
Mailing Address - Country:US
Mailing Address - Phone:239-333-8459
Mailing Address - Fax:
Practice Address - Street 1:104 LEELAND HEIGHTS BLVD W
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-6740
Practice Address - Country:US
Practice Address - Phone:239-333-8459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-333985106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician