Provider Demographics
NPI:1003648098
Name:CORAL, DIEGO
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:CORAL
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 1:3605 NW 17TH WAY APT 105
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-5863
Mailing Address - Country:US
Mailing Address - Phone:954-708-4933
Mailing Address - Fax:
Practice Address - Street 1:7601 N FEDERAL HWY STE 150A
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-1663
Practice Address - Country:US
Practice Address - Phone:754-399-8507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-17
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician