Provider Demographics
NPI:1760422125
Name:HERON-VANTA, SARA MICHELLE (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:MICHELLE
Last Name:HERON-VANTA
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:MICHELLE
Other - Last Name:CRISCUOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CF-SLP
Mailing Address - Street 1:103 WINTERGLEN DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-3688
Mailing Address - Country:US
Mailing Address - Phone:407-547-6721
Mailing Address - Fax:
Practice Address - Street 1:911 N SPRING GARDEN AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2560
Practice Address - Country:US
Practice Address - Phone:386-736-3108
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8349235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist