Provider Demographics
NPI:1831132703
Name:DIAZ, RAUL (PHD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3865 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-2853
Mailing Address - Country:US
Mailing Address - Phone:567-966-8423
Mailing Address - Fax:561-966-8424
Practice Address - Street 1:3865 10TH AVE N
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-2853
Practice Address - Country:US
Practice Address - Phone:567-966-8423
Practice Address - Fax:561-966-8424
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003808103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73360Medicare ID - Type Unspecified