=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376098178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY GUEVARA DIAZ MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2016
-----------------------------------------------------
Last Update Date | 06/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3201 NW 24TH STREET RD STE 201
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33142-6913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-646-1804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17363 SW 137TH PL
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33177-6464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-905-0877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-21-54609
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------