Provider Demographics
NPI:1083014328
Name:CRUZ-VARGAS, CHANTELLE
Entity Type:Individual
Prefix:MRS
First Name:CHANTELLE
Middle Name:
Last Name:CRUZ-VARGAS
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 1:1029 SW 124TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2466
Mailing Address - Country:US
Mailing Address - Phone:305-321-9646
Mailing Address - Fax:
Practice Address - Street 1:12030 SW 129TH CT
Practice Address - Street 2:202
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4583
Practice Address - Country:US
Practice Address - Phone:786-429-3619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6794235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist