Provider Demographics
NPI:1285268409
Name:DIAZ GARCIA, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:DIAZ GARCIA
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 1:14301 SW 258TH LN APT 4108
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6755
Mailing Address - Country:US
Mailing Address - Phone:786-765-9864
Mailing Address - Fax:
Practice Address - Street 1:13820 SW 268TH ST APT 205
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-9119
Practice Address - Country:US
Practice Address - Phone:786-765-9864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-110941106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician