Provider Demographics
NPI:1841045440
Name:DIAZ, ALEXIS M
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:M
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 1:469 BLACK KNIGHT WAY
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4467
Mailing Address - Country:US
Mailing Address - Phone:786-316-7952
Mailing Address - Fax:
Practice Address - Street 1:781 CIARA CREEK CV STE 1011
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4662
Practice Address - Country:US
Practice Address - Phone:407-699-5824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH22075101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health