Provider Demographics
NPI:1114376795
Name:DIAZ RODRIGUEZ, YANELIS (RBT)
Entity type:Individual
Prefix:
First Name:YANELIS
Middle Name:
Last Name:DIAZ RODRIGUEZ
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 1:13920 NW 22ND PL
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-4006
Mailing Address - Country:US
Mailing Address - Phone:786-704-5764
Mailing Address - Fax:
Practice Address - Street 1:13920 NW 22ND PL
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054
Practice Address - Country:US
Practice Address - Phone:786-704-5764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15-09281106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017853300Medicaid