Provider Demographics
NPI:1598493413
Name:VELEZ DIAZ, WANDA MABEL (SLP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:MABEL
Last Name:VELEZ DIAZ
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:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:PR
Mailing Address - Zip Code:00690-0303
Mailing Address - Country:US
Mailing Address - Phone:939-312-3566
Mailing Address - Fax:
Practice Address - Street 1:CARR 2, KM 122.0
Practice Address - Street 2:BO CAIMITAL ALTO
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:939-312-9233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1030235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1030OtherPROFESSIONAL WORK LICENSE