Provider Demographics
NPI:1710601190
Name:DIAZ HERNANDEZ, LIBNI DANIELA
Entity Type:Individual
Prefix:
First Name:LIBNI
Middle Name:DANIELA
Last Name:DIAZ HERNANDEZ
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 1:8120 SW 153RD PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1304
Mailing Address - Country:US
Mailing Address - Phone:786-635-4593
Mailing Address - Fax:
Practice Address - Street 1:8120 SW 153RD PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-1304
Practice Address - Country:US
Practice Address - Phone:786-635-4593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-231213106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115511900Medicaid