Provider Demographics
NPI:1750527602
Name:DE JESUS VEGA, BRENDA LIZ (SLP AND RPT)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LIZ
Last Name:DE JESUS VEGA
Suffix:
Gender:F
Credentials:SLP AND RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6062 TIVOLI GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-7702
Mailing Address - Country:US
Mailing Address - Phone:407-779-2419
Mailing Address - Fax:
Practice Address - Street 1:6062 TIVOLI GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32829-7702
Practice Address - Country:US
Practice Address - Phone:407-779-2419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-24
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1043225100000X
FLSA12884235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011132400Medicaid
PR001043OtherPHYSICAL THERAPIST