Provider Demographics
NPI:1073379608
Name:STAUDTE, MIA RAE ALISON
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:RAE ALISON
Last Name:STAUDTE
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 1:6650 LAKE PEMBROKE PL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-7619
Mailing Address - Country:US
Mailing Address - Phone:407-617-2919
Mailing Address - Fax:
Practice Address - Street 1:1107 MABBETTE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5161
Practice Address - Country:US
Practice Address - Phone:407-201-8079
Practice Address - Fax:407-343-9180
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL69052355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant