Provider Demographics
NPI:1194293688
Name:DIAZ GRACIA, YULEISY
Entity type:Individual
Prefix:
First Name:YULEISY
Middle Name:
Last Name:DIAZ GRACIA
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 1:2102 W COCO CT APT M6
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-2613
Mailing Address - Country:US
Mailing Address - Phone:813-778-8331
Mailing Address - Fax:
Practice Address - Street 1:2102 W COCO CT APT M6
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-2613
Practice Address - Country:US
Practice Address - Phone:813-778-8331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty