Healthcare Provider Details

I. General information

NPI: 1427700962
Provider Name (Legal Business Name): SUSANA DIAZ FADRAGA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2022
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 N MAIN ST
KISSIMMEE FL
34744-3304
US

IV. Provider business mailing address

1611 N MAIN ST
KISSIMMEE FL
34744-3304
US

V. Phone/Fax

Practice location:
  • Phone: 407-785-1009
  • Fax: 407-264-6443
Mailing address:
  • Phone: 407-785-1009
  • Fax: 407-264-6443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2855135
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: