Individual
DINA DECOSTA BANK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MS, CCC-SLP
Contact information
Practice address
12701 W SUNRISE BLVD, SUNRISE, FL 33323-0907
(954) 792-8772
Mailing address
1301 BANYAN WAY, WESTON, FL 33327-1623
(954) 659-9331
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
SA 5317
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
85-8012647 130C-1
TAX ID #
FL
Enumeration date
01/26/2007
Last updated
07/08/2007
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