Provider Demographics
NPI:1215166830
Name:DIAZ, STACIE S (LMT)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:S
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17224 133RD AVE
Mailing Address - Street 2:SUITE 11E
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3955
Mailing Address - Country:US
Mailing Address - Phone:917-400-1294
Mailing Address - Fax:
Practice Address - Street 1:17224 133RD AVE APT 11E
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3903
Practice Address - Country:US
Practice Address - Phone:917-400-1294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022590171W00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171W00000XOther Service ProvidersContractor