Provider Demographics
NPI:1538460324
Name:REISMAN, ILIA NICOLE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ILIA
Middle Name:NICOLE
Last Name:REISMAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12545 ORANGE DR
Mailing Address - Street 2:SUITE 502
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-4306
Mailing Address - Country:US
Mailing Address - Phone:954-474-8048
Mailing Address - Fax:
Practice Address - Street 1:12545 ORANGE DR
Practice Address - Street 2:SUITE 502
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-4306
Practice Address - Country:US
Practice Address - Phone:954-474-8048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-09
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11306235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist