Healthcare Provider Details

I. General information

NPI: 1952847006
Provider Name (Legal Business Name): DIANNE DE MENA WAGER BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DIANNE DE MENA CUE BCBA

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 SW 72ND ST STE 114
MIAMI FL
33173-3038
US

IV. Provider business mailing address

15745 SW 146TH AVE
MIAMI FL
33177-6890
US

V. Phone/Fax

Practice location:
  • Phone: 305-508-5580
  • Fax:
Mailing address:
  • Phone: 855-832-6727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-16-7503
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-34573
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: