Healthcare Provider Details

I. General information

NPI: 1508019589
Provider Name (Legal Business Name): DIANA VACCARO SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20615 FAWNBROOK CT
KATY TX
77450-8548
US

IV. Provider business mailing address

20615 FAWNBROOK CT
KATY TX
77450-8548
US

V. Phone/Fax

Practice location:
  • Phone: 646-645-2001
  • Fax: 281-829-7897
Mailing address:
  • Phone: 646-645-2001
  • Fax: 281-829-7897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number014088-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number104913
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: