Provider Demographics
NPI:1568235265
Name:DIAZ PEREZ, DEIVIS
Entity Type:Individual
Prefix:
First Name:DEIVIS
Middle Name:
Last Name:DIAZ PEREZ
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 1:8411 N SUWANEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-3068
Mailing Address - Country:US
Mailing Address - Phone:561-510-5489
Mailing Address - Fax:
Practice Address - Street 1:8411 N SUWANEE AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-3068
Practice Address - Country:US
Practice Address - Phone:561-510-5489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-305049106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician