Provider Demographics
NPI:1265259246
Name:DIAZ CHAVEZ, LIESBEL
Entity type:Individual
Prefix:
First Name:LIESBEL
Middle Name:
Last Name:DIAZ CHAVEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 GREYHOUND AVE N
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-4930
Mailing Address - Country:US
Mailing Address - Phone:239-922-0750
Mailing Address - Fax:
Practice Address - Street 1:708 GOODLETTE-FRANK RD N STE 1
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5644
Practice Address - Country:US
Practice Address - Phone:239-351-0675
Practice Address - Fax:239-310-2045
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-342772106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician