Provider Demographics
NPI:1295589638
Name:DIAZ, BRYAN FIDEL
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:FIDEL
Last Name:DIAZ
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 1:1426 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-1966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5710 W 20TH CT
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-2660
Practice Address - Country:US
Practice Address - Phone:786-564-8834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24335517106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician