Provider Demographics
NPI:1407563299
Name:DIAZ, ANGELICA PATRICIA
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:PATRICIA
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 1:1794 NW 55TH AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313-4854
Mailing Address - Country:US
Mailing Address - Phone:347-569-0790
Mailing Address - Fax:
Practice Address - Street 1:1794 NW 55TH AVE APT 103
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33313-4854
Practice Address - Country:US
Practice Address - Phone:347-569-0790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician