Healthcare Provider Details

I. General information

NPI: 1205536893
Provider Name (Legal Business Name): IVAN DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 12/30/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 E VINE ST
KISSIMMEE FL
34744-3730
US

IV. Provider business mailing address

145 E 13TH ST
SAINT CLOUD FL
34769-4749
US

V. Phone/Fax

Practice location:
  • Phone: 407-847-4152
  • Fax:
Mailing address:
  • Phone: 407-749-3580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: