Provider Demographics
NPI:1659139491
Name:DIAZ TRUJILLO, INDIRA (RBT-24-329213)
Entity type:Individual
Prefix:
First Name:INDIRA
Middle Name:
Last Name:DIAZ TRUJILLO
Suffix:
Gender:F
Credentials:RBT-24-329213
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619 LOUIS XIV CT APT D
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-5838
Mailing Address - Country:US
Mailing Address - Phone:813-442-0736
Mailing Address - Fax:
Practice Address - Street 1:2511 W VIRGINIA AVE STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6310
Practice Address - Country:US
Practice Address - Phone:813-666-8214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-329213106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician