1407879166 NPI number — MRS. IVETTE MALDONADO DIAZ LMHC

Table of content: MRS. IVETTE MALDONADO DIAZ LMHC (NPI 1407879166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407879166 NPI number — MRS. IVETTE MALDONADO DIAZ LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALDONADO DIAZ
Provider First Name:
IVETTE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407879166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1045 SW 159TH LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-430-8657
Provider Business Mailing Address Fax Number:
954-249-1975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18503 PINES BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
PEMBROKE PINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-999-4786
Provider Business Practice Location Address Fax Number:
954-999-4786
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH 8655 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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