Basic Information
| Provider Information | |||||||||
| NPI: | 1811621220 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAGENE | ||||||||
| FirstName: | KETIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 OAKWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330201956 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 OAKWOOD BLVD STE 130 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330201937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549253844 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2022 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | SI5524 | FL | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
No ID Information.