Provider Demographics
NPI:1821299181
Name:DIAZ, NELLY (BA)
Entity Type:Individual
Prefix:MS
First Name:NELLY
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2565 SE ROBIN CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7053
Mailing Address - Country:US
Mailing Address - Phone:772-240-2843
Mailing Address - Fax:
Practice Address - Street 1:709 S 5TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-8339
Practice Address - Country:US
Practice Address - Phone:772-240-2843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health