Provider Demographics
NPI:1396352357
Name:NODARSE DIAZ, MARTHA IVIS
Entity type:Individual
Prefix:
First Name:MARTHA IVIS
Middle Name:
Last Name:NODARSE 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 1:16392 SW 44TH WAY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-5338
Mailing Address - Country:US
Mailing Address - Phone:786-587-4697
Mailing Address - Fax:
Practice Address - Street 1:16392 SW 44TH WAY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-5338
Practice Address - Country:US
Practice Address - Phone:786-587-4697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty