Provider Demographics
NPI:1912169301
Name:ELIZONDO, DENISE CHANTAL (MS)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:CHANTAL
Last Name:ELIZONDO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6190 SW 128TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7133
Mailing Address - Country:US
Mailing Address - Phone:773-368-0663
Mailing Address - Fax:305-676-9091
Practice Address - Street 1:6190 SW 128TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7133
Practice Address - Country:US
Practice Address - Phone:773-368-0663
Practice Address - Fax:305-676-9091
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11015235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015129000Medicaid
FL015129000Medicaid