Healthcare Provider Details

I. General information

NPI: 1417877002
Provider Name (Legal Business Name): MARJORIS DIAZ PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11503 CANOPY LOOP
FORT MYERS FL
33913-9457
US

IV. Provider business mailing address

4410 29TH ST SW
LEHIGH ACRES FL
33973-6155
US

V. Phone/Fax

Practice location:
  • Phone: 305-917-3169
  • Fax: 888-441-6806
Mailing address:
  • Phone: 305-917-3169
  • Fax: 888-441-6806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-459500
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: