MEDICARE: DIAMOND SOUVENIR

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1942097753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIAMOND SOUVENIR

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 200
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5028
Country	:	US
Telephone Number	:	866-610-0580
Fax Number	:	866-611-1558

Provider Business Practice Location Address
First Line	:	515 PALM COAST PKWY SW STE 6/7
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32137-4739
Country	:	US
Telephone Number	:	386-951-3044
Fax Number	:

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

Provider Enumeration Date	:	04/23/2025
Last Update Date	:	03/02/2026

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Directions to “ DIAMOND SOUVENIR ” Practice Location

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