Provider Demographics
NPI:1720250715
Name:WADE COOPER, DIANNE K (AUD)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:K
Last Name:WADE COOPER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17180 ROYAL PALM BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-2394
Mailing Address - Country:US
Mailing Address - Phone:954-389-1414
Mailing Address - Fax:954-389-4201
Practice Address - Street 1:17180 ROYAL PALM BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-2394
Practice Address - Country:US
Practice Address - Phone:954-389-1414
Practice Address - Fax:954-389-4201
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY99231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001029200Medicaid
FLAL405ZMedicare PIN