Provider Demographics
NPI:1437458775
Name:DIAZ, JUAN CARLOS (BA)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:DIAZ
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 MADELINE CT
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33413-3452
Mailing Address - Country:US
Mailing Address - Phone:561-531-3242
Mailing Address - Fax:
Practice Address - Street 1:639 MADELINE CT
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33413-3452
Practice Address - Country:US
Practice Address - Phone:561-531-3242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker