Provider Demographics
NPI:1629603956
Name:DIAZ, GLADYS NEREIDA
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:NEREIDA
Last Name:DIAZ
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 1:1924 HIBISCUS LN
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-3546
Mailing Address - Country:US
Mailing Address - Phone:716-868-2396
Mailing Address - Fax:
Practice Address - Street 1:1150 S SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-1460
Practice Address - Country:US
Practice Address - Phone:407-704-7811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty