Provider Demographics
NPI:1821543935
Name:DIAZ VARELA, LISBETH
Entity Type:Individual
Prefix:
First Name:LISBETH
Middle Name:
Last Name:DIAZ VARELA
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 1:16273 SW 54TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-5005
Mailing Address - Country:US
Mailing Address - Phone:786-315-7613
Mailing Address - Fax:
Practice Address - Street 1:16273 SW 54TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-5005
Practice Address - Country:US
Practice Address - Phone:786-315-7613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-18-9061106E00000X
FL1-20-46838103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018528200Medicaid