Provider Demographics
NPI:1184075897
Name:PEGUERO, EMMANUEL
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:PEGUERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 FLAMBOYAN ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-3824
Mailing Address - Country:US
Mailing Address - Phone:407-793-9217
Mailing Address - Fax:
Practice Address - Street 1:4641 OLD CANOE CREEK RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-1550
Practice Address - Country:US
Practice Address - Phone:407-892-7344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ7591235Z00000X
FLSA15623235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist