Provider Demographics
NPI:1629888078
Name:DIAZ, KELLY (RBT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 SW 55TH ST UNIT 374
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3111
Mailing Address - Country:US
Mailing Address - Phone:786-816-0626
Mailing Address - Fax:
Practice Address - Street 1:11201 SW 55TH ST UNIT 374
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-3111
Practice Address - Country:US
Practice Address - Phone:786-816-0626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1116578106S00000X
FLBACB1116578106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician