Provider Demographics
NPI:1699740571
Name:DIAZ, MARJORIE (PT)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 SAN JACINTO CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6124
Mailing Address - Country:US
Mailing Address - Phone:407-516-3459
Mailing Address - Fax:866-378-9982
Practice Address - Street 1:2500 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3501
Practice Address - Country:US
Practice Address - Phone:407-516-3459
Practice Address - Fax:866-378-9982
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist