Healthcare Provider Details

I. General information

NPI: 1912827221
Provider Name (Legal Business Name): KELSEY MARIE DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11630 SW 55TH AVE
OCALA FL
34476-4453
US

IV. Provider business mailing address

11630 SW 55TH AVE
OCALA FL
34476-4453
US

V. Phone/Fax

Practice location:
  • Phone: 239-471-8075
  • Fax:
Mailing address:
  • Phone: 239-471-8075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP.LL.70135402
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: