Provider Demographics
NPI:1013703487
Name:VALDES DIAZ, LISANDRA
Entity type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:VALDES DIAZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9704 MARTHA RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-1327
Mailing Address - Country:US
Mailing Address - Phone:813-373-9758
Mailing Address - Fax:
Practice Address - Street 1:9704 MARTHA RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-1327
Practice Address - Country:US
Practice Address - Phone:813-373-9758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25-418145106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician