Provider Demographics
NPI:1831745512
Name:DIAZ, CHARLEEN
Entity type:Individual
Prefix:
First Name:CHARLEEN
Middle Name:
Last Name:DIAZ
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 1:771 LUCAYA DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-3279
Mailing Address - Country:US
Mailing Address - Phone:321-900-5159
Mailing Address - Fax:
Practice Address - Street 1:771 LUCAYA DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758-3279
Practice Address - Country:US
Practice Address - Phone:321-900-5159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-17
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation