Provider Demographics
NPI:1457957847
Name:DIAZ LEZCANO, SUSEJ
Entity type:Individual
Prefix:
First Name:SUSEJ
Middle Name:
Last Name:DIAZ LEZCANO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 NE 2ND TER UNIT 102
Mailing Address - Street 2:
Mailing Address - City:FLORIDA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33034-7634
Mailing Address - Country:US
Mailing Address - Phone:786-616-1089
Mailing Address - Fax:
Practice Address - Street 1:480 NE 2ND TER UNIT 102
Practice Address - Street 2:
Practice Address - City:FLORIDA CITY
Practice Address - State:FL
Practice Address - Zip Code:33034-7634
Practice Address - Country:US
Practice Address - Phone:786-616-1089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL02515865106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst