Provider Demographics
NPI:1497244339
Name:DIAZ, IDELMYS (RBT)
Entity Type:Individual
Prefix:
First Name:IDELMYS
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 TECHSTER BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-4805
Mailing Address - Country:US
Mailing Address - Phone:239-223-2751
Mailing Address - Fax:
Practice Address - Street 1:6430 PLANTATION PARK CT STE 200
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4816
Practice Address - Country:US
Practice Address - Phone:239-215-1025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician