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General NPI Number Information
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NPI Number | 1275359119
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Entity Type | Individual
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Provider Name | YISEET FAJARDO DIAZ
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Gender | Female
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Dates
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Enumeration Date | 11/25/2024
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Last Update Date | 11/25/2024
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Provider Practice Location Address
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Address Line | 820 SPING LAKE PLAZA
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City | WINTER HEAVEN
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State | FL
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Zip | 33881
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Country | US
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Telephone | 786-443-9749
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Fax |
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Provider Business Mailing Address
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Address Line | 315 PICO CT
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City | LAKELAND
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State | FL
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Zip | 33809-4234
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Country | US
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Telephone | 863-602-2594
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | RBT-24-375422
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License Number State | FL
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