Provider Demographics
NPI:1740094028
Name:DIAZ AYALA, KEISHLA LISSE
Entity type:Individual
Prefix:
First Name:KEISHLA
Middle Name:LISSE
Last Name:DIAZ AYALA
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 1:3217 HAMMERSMITH RD FL 32818
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-3094
Mailing Address - Country:US
Mailing Address - Phone:787-486-0072
Mailing Address - Fax:
Practice Address - Street 1:1201 LOUISIANA AVE STE C
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2340
Practice Address - Country:US
Practice Address - Phone:407-459-0474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13977101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health