Provider Demographics
NPI:1962623967
Name:MASSA, JOHN (MS CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:MASSA
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15225 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1802
Mailing Address - Country:US
Mailing Address - Phone:954-438-7586
Mailing Address - Fax:954-438-7586
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:TRA 491
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-1260
Practice Address - Fax:305-585-1183
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 3224235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist