Basic Information
| Provider Information | |||||||||
| NPI: | 1720250715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WADE COOPER | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17180 ROYAL PALM BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333262394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543891414 | ||||||||
| FaxNumber: | 9543894201 | ||||||||
| Practice Location | |||||||||
| Address1: | 17180 ROYAL PALM BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333262394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543891414 | ||||||||
| FaxNumber: | 9543894201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2008 | ||||||||
| LastUpdateDate: | 04/05/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AY99 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 001029200 | 05 | FL | MEDICAID |