Provider Demographics
NPI:1720281595
Name:DIAZ, MELISSA A (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8310
Mailing Address - Country:US
Mailing Address - Phone:502-259-8821
Mailing Address - Fax:
Practice Address - Street 1:9810 BLUEGRASS PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1906
Practice Address - Country:US
Practice Address - Phone:502-259-8821
Practice Address - Fax:502-259-8821
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
1-12-11464103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor