Provider Demographics
NPI:1144471186
Name:DIAZ, SUREYA ELIAS
Entity type:Individual
Prefix:
First Name:SUREYA
Middle Name:ELIAS
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 1:5818 MOHR LOOP
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-3108
Mailing Address - Country:US
Mailing Address - Phone:813-251-5290
Mailing Address - Fax:813-251-5672
Practice Address - Street 1:5818 MOHR LOOP
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-3108
Practice Address - Country:US
Practice Address - Phone:813-251-5290
Practice Address - Fax:813-251-5672
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA54107172M00000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172M00000XOther Service ProvidersMechanotherapist