Provider Demographics
NPI:1447091822
Name:DIAZ GONZALEZ, ILIANA
Entity type:Individual
Prefix:MS
First Name:ILIANA
Middle Name:
Last Name:DIAZ GONZALEZ
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 1:7480 MIAMI LAKES DR APT G107
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-6835
Mailing Address - Country:US
Mailing Address - Phone:786-771-2343
Mailing Address - Fax:
Practice Address - Street 1:7480 MIAMI LAKES DR APT G107
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-6835
Practice Address - Country:US
Practice Address - Phone:786-771-2343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-01
Last Update Date:2024-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-345798106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician