Provider Demographics
NPI:1598371114
Name:DIAZ BRAVO, LIZ MARIANA (LMT)
Entity Type:Individual
Prefix:
First Name:LIZ
Middle Name:MARIANA
Last Name:DIAZ BRAVO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6290 SW 24TH PL APT 204
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-1161
Mailing Address - Country:US
Mailing Address - Phone:561-929-5871
Mailing Address - Fax:
Practice Address - Street 1:6290 SW 24TH PL APT 204
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-1161
Practice Address - Country:US
Practice Address - Phone:561-929-5871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA88672225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist