Provider Demographics
NPI:1952001158
Name:DAZA, TIBISAY E (RBT)
Entity Type:Individual
Prefix:
First Name:TIBISAY
Middle Name:E
Last Name:DAZA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 W OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1388
Mailing Address - Country:US
Mailing Address - Phone:305-389-3224
Mailing Address - Fax:305-437-7606
Practice Address - Street 1:2701 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33311-1388
Practice Address - Country:US
Practice Address - Phone:305-389-3224
Practice Address - Fax:305-437-7606
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20140983106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician