Provider Demographics
NPI:1548570757
Name:VIVANCO, LELLANY (SLP)
Entity Type:Individual
Prefix:
First Name:LELLANY
Middle Name:
Last Name:VIVANCO
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 1:1405 SW 107TH AVE
Mailing Address - Street 2:SUITE 301-H1
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-2533
Mailing Address - Country:US
Mailing Address - Phone:305-602-8098
Mailing Address - Fax:305-602-8208
Practice Address - Street 1:1405 SW 107TH AVE
Practice Address - Street 2:SUITE 301-H1
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-2533
Practice Address - Country:US
Practice Address - Phone:305-602-8098
Practice Address - Fax:305-602-8208
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11115235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002781500Medicaid