Provider Demographics
NPI:1457957847
Name:DIAZ LEZCANO, SUSEJ
Entity Type:Individual
Prefix:
First Name:SUSEJ
Middle Name:
Last Name:DIAZ LEZCANO
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 1:6261 NW 110TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2348
Mailing Address - Country:US
Mailing Address - Phone:786-616-1089
Mailing Address - Fax:
Practice Address - Street 1:6261 NW 110TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2348
Practice Address - Country:US
Practice Address - Phone:786-616-1089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician