Healthcare Provider Details

I. General information

NPI: 1316410749
Provider Name (Legal Business Name): CHASTITI HILL VAZQUEZ-GUAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 3RD ST
ROCKLEDGE FL
32955-5703
US

IV. Provider business mailing address

4495 PAGOSA SPRINGS CIR
MELBOURNE FL
32901-8306
US

V. Phone/Fax

Practice location:
  • Phone: 321-622-8792
  • Fax: 321-622-8793
Mailing address:
  • Phone: 787-391-2123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number19267
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: