Provider Demographics
NPI:1932872074
Name:DIAZ, LISSETTE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISSETTE
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 PROSPERITY DR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3096
Mailing Address - Country:US
Mailing Address - Phone:786-282-9449
Mailing Address - Fax:
Practice Address - Street 1:1441 WINTER GARDEN VINELAND RD
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4303
Practice Address - Country:US
Practice Address - Phone:407-904-0135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA19204235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist