MEDICARE: KEILA GABRIELA DIAZ LCSW

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	1041C0700X	Clinical Social Worker	SW23342	FL

General Provider Information

NPI Number	:	1336969567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEILA GABRIELA DIAZ LCSW

Provider Business Mailing Address
First Line	:	16 S LAKE FOX RD
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-3255
Country	:	US
Telephone Number	:	689-243-8086
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 S LAKE FOX RD
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-3255
Country	:	US
Telephone Number	:	689-243-8086
Fax Number	:

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

Provider Enumeration Date	:	10/14/2024
Last Update Date	:	10/15/2024

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