Provider Demographics
NPI:1477205458
Name:ALVAREZ DIAZ, ODELAISYS
Entity type:Individual
Prefix:
First Name:ODELAISYS
Middle Name:
Last Name:ALVAREZ 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 1:925 NW 136TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2602
Mailing Address - Country:US
Mailing Address - Phone:786-560-8914
Mailing Address - Fax:
Practice Address - Street 1:925 NW 136TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33182-2602
Practice Address - Country:US
Practice Address - Phone:786-560-8914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-56926103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1-21-56926OtherBACB