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General NPI Number Information
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NPI Number | 1740094028
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Entity Type | Individual
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Provider Name | KEISHLA LISSE DIAZ AYALA
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Gender | Female
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Dates
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Enumeration Date | 02/05/2025
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Last Update Date | 02/05/2025
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Provider Practice Location Address
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Address Line | 1201 LOUISIANA AVE STE C
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City | WINTER PARK
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State | FL
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Zip | 32789-2340
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Country | US
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Telephone | 407-459-0474
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Fax |
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Provider Business Mailing Address
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Address Line | 3217 HAMMERSMITH RD FL 32818
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City | ORLANDO
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State | FL
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Zip | 32818-3094
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Country | US
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Telephone | 787-486-0072
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH13977
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License Number State | FL
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