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General NPI Number Information
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NPI Number | 1750150413
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Entity Type | Individual
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Provider Name | DIANA TAVARES DE SOUZA BUENO MT
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Gender | Female
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Dates
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Enumeration Date | 12/22/2023
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Last Update Date | 12/22/2023
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Provider Practice Location Address
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Address Line | 4400 W SAMPLE RD STE 112
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City | COCONUT CREEK
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State | FL
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Zip | 33073-3457
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Country | US
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Telephone | 954-914-5997
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Fax |
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Provider Business Mailing Address
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Address Line | 2240 N CYPRESS BEND DR APT 201
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City | POMPANO BEACH
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State | FL
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Zip | 33069-5609
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Country | US
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Telephone | 954-914-5997
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA103761
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License Number State | FL
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