Provider Demographics
NPI:1598377269
Name:BEREICUA, ESTEFANIA
Entity Type:Individual
Prefix:
First Name:ESTEFANIA
Middle Name:
Last Name:BEREICUA
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 1:1945 EMILIO LN
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-6518
Mailing Address - Country:US
Mailing Address - Phone:561-818-5691
Mailing Address - Fax:
Practice Address - Street 1:1945 EMILIO LN
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-6518
Practice Address - Country:US
Practice Address - Phone:561-818-5691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-23
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA19431235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSZ9706Medicaid