Provider Demographics
NPI:1578217600
Name:FERNANDEZ MOREJON, DIANA A
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:A
Last Name:FERNANDEZ MOREJON
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 1:1075 W 77TH ST APT 102
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3984
Mailing Address - Country:US
Mailing Address - Phone:786-226-7687
Mailing Address - Fax:
Practice Address - Street 1:1075 W 77TH ST APT 102
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-3984
Practice Address - Country:US
Practice Address - Phone:786-226-7687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-121344106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician