Provider Demographics
NPI:1619391489
Name:DIAZ MARTINEZ, IDALMYS
Entity Type:Individual
Prefix:
First Name:IDALMYS
Middle Name:
Last Name:DIAZ MARTINEZ
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:R1-17 CALLE H
Mailing Address - Street 2:TURABO GARDENS III
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-603-7012
Mailing Address - Fax:
Practice Address - Street 1:R1-17 CALLE H
Practice Address - Street 2:TURABO GARDENS III
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00727-5946
Practice Address - Country:US
Practice Address - Phone:787-603-7012
Practice Address - Fax:787-603-7012
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5438103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling