Provider Demographics
NPI:1912435850
Name:TAMAYO DIAZ, BRISEIDA O
Entity Type:Individual
Prefix:
First Name:BRISEIDA
Middle Name:O
Last Name:TAMAYO 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 1:4580 SW 128TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-4610
Mailing Address - Country:US
Mailing Address - Phone:305-588-2403
Mailing Address - Fax:305-742-2190
Practice Address - Street 1:4580 SW 128TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-4610
Practice Address - Country:US
Practice Address - Phone:305-588-2403
Practice Address - Fax:305-742-2190
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid