Provider Demographics
NPI:1992123996
Name:DIAZ, VANESSA MARIA (MS CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:VANESSA
Middle Name:MARIA
Last Name:DIAZ
Suffix:
Gender:F
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 1:7920 SW 18TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1341
Mailing Address - Country:US
Mailing Address - Phone:305-298-5980
Mailing Address - Fax:
Practice Address - Street 1:3601 NW 107TH AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4377
Practice Address - Country:US
Practice Address - Phone:786-624-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 12166235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist