Provider Demographics
NPI:1477321776
Name:DIAZ BACALLAO, YISLAINE (RBT 23-314323)
Entity type:Individual
Prefix:
First Name:YISLAINE
Middle Name:
Last Name:DIAZ BACALLAO
Suffix:
Gender:F
Credentials:RBT 23-314323
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12831 SW 209TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-7417
Mailing Address - Country:US
Mailing Address - Phone:786-258-7550
Mailing Address - Fax:
Practice Address - Street 1:850 NW FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-1019
Practice Address - Country:US
Practice Address - Phone:772-362-9878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-15
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23314323106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician