Healthcare Provider Details

I. General information

NPI: 1235781873
Provider Name (Legal Business Name): LESLIE MICHELLE DIAZ-ORTIZ PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2019
Last Update Date: 07/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8890 W OAKLAND PARK BLVD
SUNRISE FL
33351-7235
US

IV. Provider business mailing address

10419 NW 82ND ST UNIT 4
DORAL FL
33178-4093
US

V. Phone/Fax

Practice location:
  • Phone: 954-742-7032
  • Fax:
Mailing address:
  • Phone: 787-299-6873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY10504
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: