Provider Demographics
NPI:1558408344
Name:DIAZ, POTOULA (MS, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:POTOULA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 DEER PATH DR
Mailing Address - Street 2:
Mailing Address - City:OSTEEN
Mailing Address - State:FL
Mailing Address - Zip Code:32764-9824
Mailing Address - Country:US
Mailing Address - Phone:407-474-8992
Mailing Address - Fax:
Practice Address - Street 1:1340 DEER PATH DR
Practice Address - Street 2:
Practice Address - City:OSTEEN
Practice Address - State:FL
Practice Address - Zip Code:32764-9824
Practice Address - Country:US
Practice Address - Phone:407-330-7768
Practice Address - Fax:407-330-9287
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 6104101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL763878700Medicaid