Provider Demographics
NPI:1184656308
Name:DIAZ, BETHZAIDA (PTA)
Entity type:Individual
Prefix:MRS
First Name:BETHZAIDA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:BETHZAIDA
Other - Middle Name:
Other - Last Name:DIAZ LOPEZ VELEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:233 WOODINGHAM LN
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-3929
Mailing Address - Country:US
Mailing Address - Phone:941-493-9697
Mailing Address - Fax:941-484-5487
Practice Address - Street 1:333 TAMIAMI TRL S
Practice Address - Street 2:SUITE 207
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2402
Practice Address - Country:US
Practice Address - Phone:941-484-2471
Practice Address - Fax:941-484-5487
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA2088225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant