Provider Demographics
NPI:1467502542
Name:VANAMBURG, ALEISHA WILBER (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:ALEISHA
Middle Name:WILBER
Last Name:VANAMBURG
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:207 CRYSTAL GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-6409
Mailing Address - Country:US
Mailing Address - Phone:813-848-0341
Mailing Address - Fax:813-540-8271
Practice Address - Street 1:207 CRYSTAL GROVE BLVD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-6409
Practice Address - Country:US
Practice Address - Phone:813-848-0341
Practice Address - Fax:813-540-8271
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLSA6573235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887426300Medicaid
FLS2436OtherBLUE CROSS BLUE SHIELD
FLHI331ZMedicare PIN
FL887426300Medicaid