Provider Demographics
NPI:1558875567
Name:DIAZ, MARCOS EMILIO
Entity Type:Individual
Prefix:
First Name:MARCOS
Middle Name:EMILIO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3513 S OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405-1933
Mailing Address - Country:US
Mailing Address - Phone:321-506-1215
Mailing Address - Fax:
Practice Address - Street 1:3513 S OLIVE AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33405-1933
Practice Address - Country:US
Practice Address - Phone:321-506-1215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician