Provider Demographics
NPI:1235941030
Name:DIAZ, LISMARY
Entity type:Individual
Prefix:
First Name:LISMARY
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 WORTHMORE DR
Mailing Address - Street 2:HOME
Mailing Address - City:LAKE WORTH BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33460
Mailing Address - Country:US
Mailing Address - Phone:561-719-1129
Mailing Address - Fax:
Practice Address - Street 1:513 WORTHMORE DR
Practice Address - Street 2:HOME
Practice Address - City:LAKE WORTH BEACH
Practice Address - State:FL
Practice Address - Zip Code:33460
Practice Address - Country:US
Practice Address - Phone:561-719-1129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-405420106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty