Provider Demographics
NPI:1558131789
Name:SOTO DIAZ, IRINA
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:SOTO 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 1:632 BOARDWALK AVE
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-8486
Mailing Address - Country:US
Mailing Address - Phone:863-348-1654
Mailing Address - Fax:
Practice Address - Street 1:632 BOARDWALK AVE
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-8486
Practice Address - Country:US
Practice Address - Phone:863-348-1654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-297999106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty