Healthcare Provider Details

I. General information

NPI: 1407374192
Provider Name (Legal Business Name): ELIZABETH MARIA DIEZ LICEA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2017
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 SW 216TH ST
CUTLER BAY FL
33190-1003
US

IV. Provider business mailing address

13371 SW 17TH LN APT 8
MIAMI FL
33175-7634
US

V. Phone/Fax

Practice location:
  • Phone: 305-253-5100
  • Fax:
Mailing address:
  • Phone: 786-230-0590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW22055
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW22055
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: