Provider Demographics
NPI:1356738652
Name:DIAZ, GABRIELA
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:
Last Name:DIAZ
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 1:260 CROSSFIELD DR
Mailing Address - Street 2:UNIT 2
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1596
Mailing Address - Country:US
Mailing Address - Phone:859-879-0024
Mailing Address - Fax:859-879-1102
Practice Address - Street 1:260 CROSSFIELD DR
Practice Address - Street 2:UNIT 2
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1596
Practice Address - Country:US
Practice Address - Phone:859-879-0024
Practice Address - Fax:859-879-1102
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYBMTMTH00216686225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist