Provider Demographics
NPI:1558805069
Name:DIAZ PANDO, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DIAZ PANDO
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 1:20541 SW 79TH CT
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-2184
Mailing Address - Country:US
Mailing Address - Phone:786-991-3706
Mailing Address - Fax:786-206-7074
Practice Address - Street 1:20541 SW 79TH CT
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-2184
Practice Address - Country:US
Practice Address - Phone:786-991-3706
Practice Address - Fax:786-206-7074
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBCABA-0-21-13217106E00000X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019539000Medicaid