Provider Demographics
NPI:1851832935
Name:DIAZ CABRERA, GUILLERMO A
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:A
Last Name:DIAZ CABRERA
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 1:7195 NW 179TH ST APT 111
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-6284
Mailing Address - Country:US
Mailing Address - Phone:786-720-5170
Mailing Address - Fax:
Practice Address - Street 1:18821 NW 84TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5350
Practice Address - Country:US
Practice Address - Phone:786-720-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-117285106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020243400Medicaid