Provider Demographics
NPI:1508570730
Name:DIAZ, MARY A
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
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 1:16283 SW 76TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-3445
Mailing Address - Country:US
Mailing Address - Phone:305-323-4260
Mailing Address - Fax:
Practice Address - Street 1:16283 SW 76TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-3445
Practice Address - Country:US
Practice Address - Phone:305-323-4260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
22-247049106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician