Provider Demographics
NPI:1699375485
Name:JOSEPH, VIOLANGE
Entity Type:Individual
Prefix:
First Name:VIOLANGE
Middle Name:
Last Name:JOSEPH
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 1:3310 SW FRANKFORD ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-4937
Mailing Address - Country:US
Mailing Address - Phone:786-326-8742
Mailing Address - Fax:
Practice Address - Street 1:3310 SW FRANKFORD ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-4937
Practice Address - Country:US
Practice Address - Phone:786-326-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJ210-860-84-872-0OtherDRIVER LICENSE
FLJ210860848720OtherDRIVER LICENSE