Provider Demographics
NPI:1659135580
Name:CARDENAS DIAZ, MILDREY
Entity Type:Individual
Prefix:
First Name:MILDREY
Middle Name:
Last Name:CARDENAS 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 1:1051 CHERYL RD
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33417-5801
Mailing Address - Country:US
Mailing Address - Phone:561-329-1025
Mailing Address - Fax:
Practice Address - Street 1:3066 S JOG RD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33467-2053
Practice Address - Country:US
Practice Address - Phone:561-788-4086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty