Provider Demographics
NPI:1629321484
Name:DIAK, TERESA 'TERRY' (LMHC)
Entity Type:Individual
Prefix:MS
First Name:TERESA 'TERRY'
Middle Name:
Last Name:DIAK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 EICHENFELD DRIVE
Mailing Address - Street 2:SUITE #106
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5985
Mailing Address - Country:US
Mailing Address - Phone:813-689-1895
Mailing Address - Fax:813-689-4328
Practice Address - Street 1:505 EICHENFELD DRIVE
Practice Address - Street 2:SUITE #106
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5985
Practice Address - Country:US
Practice Address - Phone:813-689-1895
Practice Address - Fax:813-689-4328
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4191101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ050TOtherBLUE CROSS, BLUE SHIELD OUT-OF-NETWORK PROVIDER NUMBER