Basic Information
| Provider Information | |||||||||
| NPI: | 1699234963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DODARD | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | V | ||||||||
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| Mailing Information | |||||||||
| Address1: | 757 DONAU AVE NW | ||||||||
| Address2: | |||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329078202 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 CLARK ST | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327657378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073595693 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2019 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.