Provider Demographics
NPI:1376608018
Name:HEREDIA, LYNDA
Entity Type:Individual
Prefix:
First Name:LYNDA
Middle Name:
Last Name:HEREDIA
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 1:401 MIRACLE MILE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4930
Mailing Address - Country:US
Mailing Address - Phone:305-446-1098
Mailing Address - Fax:305-446-1638
Practice Address - Street 1:401 MIRACLE MILE
Practice Address - Street 2:SUITE 403
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-4930
Practice Address - Country:US
Practice Address - Phone:305-446-1098
Practice Address - Fax:305-446-1638
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 3155235Z00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL812147800Medicaid
FL888005100Medicaid