Healthcare Provider Details

I. General information

NPI: 1336054113
Provider Name (Legal Business Name): DEZIRE DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1009 W MAIN ST
MOUNT JOY PA
17552-9666
US

IV. Provider business mailing address

104 EAGLE PATH
MOUNTVILLE PA
17554-1859
US

V. Phone/Fax

Practice location:
  • Phone: 301-635-2273
  • Fax:
Mailing address:
  • Phone: 717-201-8950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: