Provider Demographics
NPI:1770162232
Name:DURAN MARTIN, DIANELYS
Entity type:Individual
Prefix:
First Name:DIANELYS
Middle Name:
Last Name:DURAN MARTIN
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 1:13995 SW 150TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-5038
Mailing Address - Country:US
Mailing Address - Phone:786-327-0880
Mailing Address - Fax:
Practice Address - Street 1:7965 SW 164TH PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-5779
Practice Address - Country:US
Practice Address - Phone:727-421-6015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-119442OtherRBT