Healthcare Provider Details

I. General information

NPI: 1023573789
Provider Name (Legal Business Name): MICHELLE MARIE RODRIGUEZ DIAZ PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 MEADOW POND WAY
ORLANDO FL
32824-5060
US

IV. Provider business mailing address

2043 MEADOW POND WAY
ORLANDO FL
32824-5060
US

V. Phone/Fax

Practice location:
  • Phone: 305-613-1338
  • Fax:
Mailing address:
  • Phone: 305-613-1338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPY10360
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY10360
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: