Provider Demographics
NPI:1336905397
Name:DOVALE, DIANA MILENA (BS, ITDS)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MILENA
Last Name:DOVALE
Suffix:
Gender:F
Credentials:BS, ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 SW TODD AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2913
Mailing Address - Country:US
Mailing Address - Phone:305-582-1495
Mailing Address - Fax:
Practice Address - Street 1:433 SW TODD AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-2913
Practice Address - Country:US
Practice Address - Phone:305-582-1495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist