Provider Demographics
NPI:1417169053
Name:BRAVO BUCKINGHAM, MARIA MONICA (SLP)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:MONICA
Last Name:BRAVO BUCKINGHAM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 SAWGRASS PINE CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-4890
Mailing Address - Country:US
Mailing Address - Phone:321-663-4076
Mailing Address - Fax:321-663-4076
Practice Address - Street 1:6000 S RIO GRANDE AVE STE 206
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4650
Practice Address - Country:US
Practice Address - Phone:407-280-3776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA21094235Z00000X
FLSZ 7052235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist