Provider Demographics
NPI:1770220980
Name:DIAZ QUINTERO, MIDIALYS (RBT)
Entity Type:Individual
Prefix:
First Name:MIDIALYS
Middle Name:
Last Name:DIAZ QUINTERO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17730 NW 67TH AVE APT 515
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5809
Mailing Address - Country:US
Mailing Address - Phone:786-690-1299
Mailing Address - Fax:
Practice Address - Street 1:17730 NW 67TH AVE APT 515
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5809
Practice Address - Country:US
Practice Address - Phone:786-690-1299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-193053106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty