Provider Demographics
NPI:1912112673
Name:VANCE-COLLIER, DIEDRE MICHELLE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:DIEDRE
Middle Name:MICHELLE
Last Name:VANCE-COLLIER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3923 LOCKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-8047
Mailing Address - Country:US
Mailing Address - Phone:678-758-7291
Mailing Address - Fax:813-948-9567
Practice Address - Street 1:3923 LOCKRIDGE DR
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-8047
Practice Address - Country:US
Practice Address - Phone:678-758-7291
Practice Address - Fax:813-948-9567
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004038235Z00000X
FLSA 8665235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8918422Medicaid