Provider Demographics
NPI:1417574948
Name:MENA DIAZ, NICOLE INELL (RBT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:INELL
Last Name:MENA DIAZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 W 49TH PL APT 312
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-8153
Mailing Address - Country:US
Mailing Address - Phone:305-930-0325
Mailing Address - Fax:
Practice Address - Street 1:1335 W 49TH PL APT 312
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-8153
Practice Address - Country:US
Practice Address - Phone:305-930-0325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician