Provider Demographics
NPI:1104481191
Name:DIAZ, YACKLIN CARMEN
Entity type:Individual
Prefix:
First Name:YACKLIN
Middle Name:CARMEN
Last Name: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 1:9345 W 32ND LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-2063
Mailing Address - Country:US
Mailing Address - Phone:786-631-7370
Mailing Address - Fax:
Practice Address - Street 1:9345 W 32ND LN
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-2063
Practice Address - Country:US
Practice Address - Phone:786-631-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-05
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-25-79599103K00000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
103K00000XOtherPRIVATE INSURANCE