MEDICARE: MS. MARISSA ALICIA DIAZ

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1821303975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARISSA ALICIA DIAZ

Provider Business Mailing Address
First Line	:	3500 N STATE ROAD 7
Second Line	:	SUITE 211
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33319-5600
Country	:	US
Telephone Number	:	954-978-8399
Fax Number	:	954-578-0145

Provider Business Practice Location Address
First Line	:	6000 PALM TRACE LANDING DR
Second Line	:	APT 204
City	:	DAVIE
State	:	FL
Zip	:	33314-1835
Country	:	US
Telephone Number	:	954-854-5532
Fax Number	:

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

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	08/13/2010

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