Provider Demographics
NPI:1023476215
Name:DISLA, JUDITH ESTHER
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:ESTHER
Last Name:DISLA
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 1:11110 CREEK HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-6206
Mailing Address - Country:US
Mailing Address - Phone:813-842-8004
Mailing Address - Fax:813-873-8837
Practice Address - Street 1:16102 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-6129
Practice Address - Country:US
Practice Address - Phone:813-873-1936
Practice Address - Fax:813-873-8837
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist