=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629080874
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNBRIDELED FASHIION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 COCHRAN RD
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32732-9294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-325-8035
-----------------------------------------------------
Fax | 407-349-2253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 905 COCHRAN RD
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32732-9294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-325-8035
-----------------------------------------------------
Fax | 407-349-2253
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS PARTNER
-----------------------------------------------------
Name | MS. DANA L VANZANDT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-325-8035
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA3515
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------