Provider Demographics
NPI:1538647656
Name:DIEZ, STEPHANIE LEE (LCSW, MCAP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LEE
Last Name:DIEZ
Suffix:
Gender:F
Credentials:LCSW, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4564 SW 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-5429
Mailing Address - Country:US
Mailing Address - Phone:786-505-6419
Mailing Address - Fax:
Practice Address - Street 1:946 40TH ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34234-4320
Practice Address - Country:US
Practice Address - Phone:786-505-6419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW152151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical