Healthcare Provider Details

I. General information

NPI: 1104512250
Provider Name (Legal Business Name): ALYSSA NICOLE DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11276 SW 232ND ST
GOULDS FL
33170-7505
US

IV. Provider business mailing address

15617 SW 62ND TER
MIAMI FL
33193-2583
US

V. Phone/Fax

Practice location:
  • Phone: 305-912-8399
  • Fax:
Mailing address:
  • Phone: 786-307-8113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-88122
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: