Provider Demographics
NPI:1417416397
Name:DIAZ, MARCY
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:
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 1:777 BRICKELL AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33131-2803
Mailing Address - Country:US
Mailing Address - Phone:305-330-4660
Mailing Address - Fax:786-217-1376
Practice Address - Street 1:777 BRICKELL AVE STE 500
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33131-2803
Practice Address - Country:US
Practice Address - Phone:305-330-4660
Practice Address - Fax:786-217-1376
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-06-2809103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1154667681Medicaid