Provider Demographics
NPI:1134172505
Name:DIAZ, CARMEN B (PHD)
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:B
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9421 SW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-3027
Mailing Address - Country:US
Mailing Address - Phone:305-485-1552
Mailing Address - Fax:305-274-0692
Practice Address - Street 1:2100 PONCE DE LEON BLVD STE 1015
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-5240
Practice Address - Country:US
Practice Address - Phone:786-514-8812
Practice Address - Fax:305-274-0692
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4145103T00000X
103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPY4145OtherMEDICAL LICENSE #
FLPY4145OtherMEDICAL LICENSE #