Provider Demographics
NPI:1275359119
Name:FAJARDO DIAZ, YISEET
Entity type:Individual
Prefix:
First Name:YISEET
Middle Name:
Last Name:FAJARDO 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 1:315 PICO CT
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4234
Mailing Address - Country:US
Mailing Address - Phone:863-602-2594
Mailing Address - Fax:
Practice Address - Street 1:820 SPING LAKE PLAZA
Practice Address - Street 2:
Practice Address - City:WINTER HEAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881
Practice Address - Country:US
Practice Address - Phone:786-443-9749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-375422106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician