Provider Demographics
NPI:1306261607
Name:BRENDA LIZ DE JESUS VEGA
Entity type:Organization
Organization Name:BRENDA LIZ DE JESUS VEGA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH AND LANGUAGE PATHOLOGY
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LIZ
Authorized Official - Last Name:DE JESUS VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MSSLP-CCC
Authorized Official - Phone:407-779-2419
Mailing Address - Street 1:6062 TIVOLI GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-7702
Mailing Address - Country:US
Mailing Address - Phone:407-779-2419
Mailing Address - Fax:
Practice Address - Street 1:6062 TIVOLI GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32829-7702
Practice Address - Country:US
Practice Address - Phone:407-779-2419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-23
Last Update Date:2014-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ5973261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech