Individual
DIANE ROSE WAKEFIELD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
6113 PHEASANT RIDGE DR, PORT ORANGE, FL 32128-6988
(386) 334-0183
Mailing address
6113 PHEASANT RIDGE DR, PORT ORANGE, FL 32128-6988
(386) 334-0183
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
—
—
252Y00000X
Early Intervention Provider Agency
Primary
—
FL
Other
Enumeration date
11/15/2017
Last updated
01/27/2019
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