Healthcare Provider Details

I. General information

NPI: 1932654126
Provider Name (Legal Business Name): GILBERTO DIAZ PONCE BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 NW FAIRFAX AVE
PORT SAINT LUCIE FL
34983-1017
US

IV. Provider business mailing address

557 NW FAIRFAX AVE
PORT SAINT LUCIE FL
34983-1017
US

V. Phone/Fax

Practice location:
  • Phone: 786-355-1870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: