MEDICARE: IRASEMA DIAZ HERNANDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1811523921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRASEMA DIAZ HERNANDEZ

Provider Business Mailing Address
First Line	:	1639 WOODLAND DR
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-1000
Country	:	US
Telephone Number	:	208-576-5005
Fax Number	:

Provider Business Practice Location Address
First Line	:	1140 W 1130 S
Second Line	:	BUILDING B
City	:	OREM
State	:	UT
Zip	:	84058-2888
Country	:	US
Telephone Number	:	385-227-8653
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2020
Last Update Date	:	03/20/2020

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