Provider Demographics
NPI:1316316359
Name:LA VILLA, RANDY (SLP)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:LA VILLA
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W 67TH PL APT 24
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-2816
Mailing Address - Country:US
Mailing Address - Phone:305-873-9720
Mailing Address - Fax:305-541-3344
Practice Address - Street 1:7872 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144
Practice Address - Country:US
Practice Address - Phone:786-360-5029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14812235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015746800Medicaid
FLSA14812OtherLICENSE UPDATE