Provider Demographics
NPI:1134666894
Name:DIAZ COLINA, MARIA JOSE
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:JOSE
Last Name:DIAZ COLINA
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 1:7585 SW 152ND AVE APT G104
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2373
Mailing Address - Country:US
Mailing Address - Phone:305-345-2738
Mailing Address - Fax:
Practice Address - Street 1:8300 W FLAGLER ST STE 170
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2098
Practice Address - Country:US
Practice Address - Phone:786-633-5171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH25341101YM0800X
FL1-24-75333103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019574300Medicaid