Provider Demographics
NPI:1497334569
Name:AYALA PEREZ, DIANNE
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:AYALA PEREZ
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 1:18081 BASS LAKE CT
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33972-4803
Mailing Address - Country:US
Mailing Address - Phone:239-848-6612
Mailing Address - Fax:
Practice Address - Street 1:18081 BASS LAKE CT
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33972-4803
Practice Address - Country:US
Practice Address - Phone:239-848-6612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT-20-143684106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician