Provider Demographics
NPI:1144974775
Name:DIAZ, CHRISOPHER GONZALEZ (RBT)
Entity type:Individual
Prefix:
First Name:CHRISOPHER
Middle Name:GONZALEZ
Last Name:DIAZ
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18646 NW 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-5307
Mailing Address - Country:US
Mailing Address - Phone:305-680-6417
Mailing Address - Fax:
Practice Address - Street 1:18646 NW 53RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-5307
Practice Address - Country:US
Practice Address - Phone:305-680-6417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-136830103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1085698000Medicaid