Provider Demographics
NPI:1316682008
Name:CASAS DIAZ, JORGE LUIS
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:CASAS 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 1:10284 NW 9TH STREET CIR APT 203
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-3245
Mailing Address - Country:US
Mailing Address - Phone:813-447-7122
Mailing Address - Fax:
Practice Address - Street 1:10284 NW 9TH STREET CIR APT 203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-3245
Practice Address - Country:US
Practice Address - Phone:813-447-7122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-119000106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician