Provider Demographics
NPI:1205314168
Name:DIAZ MASIP, MILDRED
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:DIAZ MASIP
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 1:1106 NW 18TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-5902
Mailing Address - Country:US
Mailing Address - Phone:239-308-7537
Mailing Address - Fax:
Practice Address - Street 1:1106 NW 18TH PL
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33993-5902
Practice Address - Country:US
Practice Address - Phone:239-308-7537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-21-11943106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst