Provider Demographics
NPI:1801030085
Name:DIAZ, CARLOS RAFAEL
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:RAFAEL
Last Name:DIAZ
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 1:1450 SW 63RD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-5638
Mailing Address - Country:US
Mailing Address - Phone:786-942-9403
Mailing Address - Fax:
Practice Address - Street 1:1450 SW 63RD AVE
Practice Address - Street 2:
Practice Address - City:WEST MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-5638
Practice Address - Country:US
Practice Address - Phone:786-942-9403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-14-6271106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst