Basic Information
| Provider Information | |||||||||
| NPI: | 1023554698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAMB | ||||||||
| FirstName: | DEANNA | ||||||||
| MiddleName: | CARREIRA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED. CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARREIRA | ||||||||
| OtherFirstName: | DEANNA | ||||||||
| OtherMiddleName: | CAROL | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.ED. CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16748 FAIRBOLT WAY | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335566031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126749776 | ||||||||
| FaxNumber: | 8132640768 | ||||||||
| Practice Location | |||||||||
| Address1: | 6508 GUNN HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336254022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139636923 | ||||||||
| FaxNumber: | 8132640768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2017 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SZ7932 | FL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SA16009 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 019687200 | 05 | FL | MEDICAID |