MEDICARE: DAIMA PICO-GUARDADO PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PY005556	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	54139	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1003861097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAIMA PICO-GUARDADO PSYD

Provider Business Mailing Address
First Line	:	5200 NE 2ND AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33137-2706
Country	:	US
Telephone Number	:	305-532-7246
Fax Number	:	305-534-3974

Provider Business Practice Location Address
First Line	:	5200 NE 2ND AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33137-2706
Country	:	US
Telephone Number	:	305-532-7246
Fax Number	:	305-534-3974

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	03/03/2010

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