Provider Demographics
NPI:1922609601
Name:DIAZ, IVELIS (RBT)
Entity Type:Individual
Prefix:MRS
First Name:IVELIS
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14359 MIRAMAR PKWY STE 504
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4134
Mailing Address - Country:US
Mailing Address - Phone:954-526-1592
Mailing Address - Fax:
Practice Address - Street 1:1800 N DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-3200
Practice Address - Country:US
Practice Address - Phone:954-526-1592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT20119913106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician