Provider Demographics
NPI:1679317416
Name:DIAZ CORRALES, LIANET
Entity type:Individual
Prefix:
First Name:LIANET
Middle Name:
Last Name:DIAZ CORRALES
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 1:504 BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-4229
Mailing Address - Country:US
Mailing Address - Phone:863-210-8926
Mailing Address - Fax:
Practice Address - Street 1:504 BENNETT ST
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-4229
Practice Address - Country:US
Practice Address - Phone:863-210-8926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-353168106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty