Provider Demographics
NPI:1821303975
Name:DIAZ, MARISSA ALICIA
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:ALICIA
Last Name:DIAZ
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 1:3500 N STATE ROAD 7
Mailing Address - Street 2:SUITE 211
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5600
Mailing Address - Country:US
Mailing Address - Phone:954-978-8399
Mailing Address - Fax:954-578-0145
Practice Address - Street 1:6000 PALM TRACE LANDING DR
Practice Address - Street 2:APT 204
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-1835
Practice Address - Country:US
Practice Address - Phone:954-854-5532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor