Provider Demographics
NPI:1598074445
Name:DIAZ REYES, LOURDES (BCBA)
Entity Type:Individual
Prefix:MISS
First Name:LOURDES
Middle Name:
Last Name:DIAZ REYES
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7615 SW 129TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-4244
Mailing Address - Country:US
Mailing Address - Phone:786-859-1068
Mailing Address - Fax:866-275-3940
Practice Address - Street 1:7615 SW 129TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-4244
Practice Address - Country:US
Practice Address - Phone:786-859-1068
Practice Address - Fax:866-275-3940
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-14-16542103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003720300Medicaid