Provider Demographics
NPI:1407973233
Name:AGRESTA-DIAZ, LILLIAN PAULINE (MS)
Entity type:Individual
Prefix:MS
First Name:LILLIAN
Middle Name:PAULINE
Last Name:AGRESTA-DIAZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3656 2ND PL SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32968-3172
Mailing Address - Country:US
Mailing Address - Phone:631-484-5395
Mailing Address - Fax:772-584-3204
Practice Address - Street 1:3656 2ND PL SW
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32968-3172
Practice Address - Country:US
Practice Address - Phone:631-484-5395
Practice Address - Fax:772-584-3204
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003505-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist