Provider Demographics
NPI:1992508428
Name:DIAZ, CARMEN LISANDRA
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:LISANDRA
Last Name:DIAZ
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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2010 CROW CANYON PL STE 100
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1344
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician