Provider Demographics
NPI:1750150413
Name:TAVARES DE SOUZA BUENO, DIANA (MT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:TAVARES DE SOUZA BUENO
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 N CYPRESS BEND DR APT 201
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-5609
Mailing Address - Country:US
Mailing Address - Phone:954-914-5997
Mailing Address - Fax:
Practice Address - Street 1:4400 W SAMPLE RD STE 112
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-3457
Practice Address - Country:US
Practice Address - Phone:954-914-5997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA103761225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty