Provider Demographics
NPI:1760167266
Name:DIAZ VALDIVIA, VICTOR MANUEL
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:MANUEL
Last Name:DIAZ VALDIVIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27000 SW 142ND PL
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-7537
Mailing Address - Country:US
Mailing Address - Phone:786-876-0040
Mailing Address - Fax:
Practice Address - Street 1:27000 SW 142ND PL
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-7537
Practice Address - Country:US
Practice Address - Phone:786-876-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-277098106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician