Provider Demographics
NPI:1912405739
Name:DIAZ FERNANDEZ, ADISNAY
Entity Type:Individual
Prefix:
First Name:ADISNAY
Middle Name:
Last Name:DIAZ FERNANDEZ
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 1:701 NE 1ST CT APT 111
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4447
Mailing Address - Country:US
Mailing Address - Phone:786-663-8185
Mailing Address - Fax:
Practice Address - Street 1:701 NE 1ST CT APT 111
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4447
Practice Address - Country:US
Practice Address - Phone:786-663-8185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCMS101000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1043635972Medicaid