Healthcare Provider Details

I. General information

NPI: 1265259246
Provider Name (Legal Business Name): LIESBEL DIAZ CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 GOODLETTE-FRANK RD N STE 1
NAPLES FL
34102-5644
US

IV. Provider business mailing address

800 GREYHOUND AVE N
LEHIGH ACRES FL
33971-4930
US

V. Phone/Fax

Practice location:
  • Phone: 239-351-0675
  • Fax: 239-310-2045
Mailing address:
  • Phone: 239-922-0750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-342772
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: