Provider Demographics
NPI:1285488668
Name:DIAZ, KRISTIAN JOSE
Entity type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:JOSE
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1158 SW 131ST PLACE CIR N
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2009
Mailing Address - Country:US
Mailing Address - Phone:786-515-5285
Mailing Address - Fax:
Practice Address - Street 1:1158 SW 131ST PLACE CIR N
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-2009
Practice Address - Country:US
Practice Address - Phone:786-515-5285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-334352106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician