Healthcare Provider Details

I. General information

NPI: 1134172505
Provider Name (Legal Business Name): CARMEN B DIAZ PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 PONCE DE LEON BLVD STE 1015
CORAL GABLES FL
33134-5240
US

IV. Provider business mailing address

9421 SW 12TH ST
MIAMI FL
33174-3027
US

V. Phone/Fax

Practice location:
  • Phone: 786-514-8812
  • Fax: 305-274-0692
Mailing address:
  • Phone: 305-485-1552
  • Fax: 305-274-0692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY4145
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: