Provider Demographics
NPI:1467992594
Name:DIAZ, LISSAINET (BCBA)
Entity Type:Individual
Prefix:
First Name:LISSAINET
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9143 SW 77TH AVE APT B803
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7656
Mailing Address - Country:US
Mailing Address - Phone:786-346-1123
Mailing Address - Fax:
Practice Address - Street 1:3520 OAKS WAY APT 904
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-5387
Practice Address - Country:US
Practice Address - Phone:305-807-1909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-21-53255103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician