Basic Information
| Provider Information | |||||||||
| NPI: | 1629251673 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANG-RIVERA | ||||||||
| FirstName: | DIANELZA | ||||||||
| MiddleName: | R. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14221 SW 120TH ST. | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331864224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7863910818 | ||||||||
| FaxNumber: | 7866092019 | ||||||||
| Practice Location | |||||||||
| Address1: | 14221 SW 120TH ST. | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331864224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7863910818 | ||||||||
| FaxNumber: | 7866092019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2007 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 811905800 | 05 | FL | MEDICAID |