=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346624483
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERTO DIAZ LMHC, NCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2015
-----------------------------------------------------
Last Update Date | 07/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11850 NW 41ST ST
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33323-3612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-673-9408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2645 EXECUTIVE PARK DR SUITE 513
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33331-3624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH6578
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------