Provider Demographics
NPI:1518463363
Name:MORA BLAZQUEZ, CLARA ROSA (SLP)
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:ROSA
Last Name:MORA BLAZQUEZ
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 1:11747 SW 99TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-2752
Mailing Address - Country:US
Mailing Address - Phone:786-424-0936
Mailing Address - Fax:
Practice Address - Street 1:11747 SW 99TH LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-2752
Practice Address - Country:US
Practice Address - Phone:786-424-0936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
FLSA20817235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician