Provider Demographics
NPI:1104512250
Name:DIAZ, ALYSSA NICOLE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:NICOLE
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 1:15617 SW 62ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2583
Mailing Address - Country:US
Mailing Address - Phone:786-307-8113
Mailing Address - Fax:
Practice Address - Street 1:11276 SW 232ND ST
Practice Address - Street 2:
Practice Address - City:GOULDS
Practice Address - State:FL
Practice Address - Zip Code:33170-7505
Practice Address - Country:US
Practice Address - Phone:305-912-8399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-265382106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician