=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538908512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA MARIE NIEVES THL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2024
-----------------------------------------------------
Last Update Date | 05/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 CALLE MJ CABRERO
-----------------------------------------------------
City | SAN SEBASTIAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00685-4843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-955-0270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1748 BO TABLONAL
-----------------------------------------------------
City | AGUADA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00602-2439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 939-323-3796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | 007606
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------