MEDICARE: BRISEIDA O TAMAYO 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	103K00000X	Behavior Analyst
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1912435850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRISEIDA O TAMAYO DIAZ

Provider Business Mailing Address
First Line	:	4580 SW 128TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-4610
Country	:	US
Telephone Number	:	305-588-2403
Fax Number	:	305-742-2190

Provider Business Practice Location Address
First Line	:	4580 SW 128TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-4610
Country	:	US
Telephone Number	:	305-588-2403
Fax Number	:	305-742-2190

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

Provider Enumeration Date	:	05/23/2017
Last Update Date	:	07/21/2022

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