Provider Demographics
NPI:1952847006
Name:WAGER, DIANNE DE MENA (BCBA)
Entity type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:DE MENA
Last Name:WAGER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MS
Other - First Name:DIANNE
Other - Middle Name:
Other - Last Name:DE MENA CUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:15745 SW 146TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-6890
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:10300 SW 72ND ST STE 114
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3038
Practice Address - Country:US
Practice Address - Phone:305-508-5580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-16-7503103K00000X
FL1-19-34573103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst