Provider Demographics
NPI:1770633638
Name:WERTZ, DIANE (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:WERTZ
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 NW 50TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-3171
Mailing Address - Country:US
Mailing Address - Phone:352-665-1217
Mailing Address - Fax:
Practice Address - Street 1:4423 NW 6TH PL
Practice Address - Street 2:SUITE C
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-6115
Practice Address - Country:US
Practice Address - Phone:352-379-8555
Practice Address - Fax:352-379-8585
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4409235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891765500Medicaid