MEDICARE: DIEGO SAMUEL FERNANDEZ VASALLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-24-380473	FL

General Provider Information

NPI Number	:	1346061819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIEGO SAMUEL FERNANDEZ VASALLO

Provider Business Mailing Address
First Line	:	9620 SW 142ND CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-1178
Country	:	US
Telephone Number	:	786-817-3040
Fax Number	:

Provider Business Practice Location Address
First Line	:	9620 SW 142ND CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-1178
Country	:	US
Telephone Number	:	786-817-3040
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2024
Last Update Date	:	10/18/2024

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Directions to “ DIEGO SAMUEL FERNANDEZ VASALLO ” Practice Location

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