Provider Demographics
NPI:1952069734
Name:HEREDIA PAIS, DIANISVEY C
Entity Type:Individual
Prefix:
First Name:DIANISVEY
Middle Name:C
Last Name:HEREDIA PAIS
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 1:6830 SW 132ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-2382
Mailing Address - Country:US
Mailing Address - Phone:786-695-2240
Mailing Address - Fax:
Practice Address - Street 1:6830 SW 132ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-2382
Practice Address - Country:US
Practice Address - Phone:786-878-0159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20140340106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109080700Medicaid