Provider Demographics
NPI:1003115809
Name:DE LA TORRE, JODI TICE
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:TICE
Last Name:DE LA TORRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2731 OAKBROOK MNR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33332-3429
Mailing Address - Country:US
Mailing Address - Phone:954-389-2206
Mailing Address - Fax:
Practice Address - Street 1:5979 NW 151ST ST
Practice Address - Street 2:SUITE 108
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2400
Practice Address - Country:US
Practice Address - Phone:305-362-3300
Practice Address - Fax:305-362-0202
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA669235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist