Provider Demographics
NPI:1174403901
Name:VARELA, PHOENIX MAE
Entity type:Individual
Prefix:
First Name:PHOENIX
Middle Name:MAE
Last Name:VARELA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 WINNEBAGO TRL
Mailing Address - Street 2:
Mailing Address - City:FERN PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32730-3020
Mailing Address - Country:US
Mailing Address - Phone:305-333-1672
Mailing Address - Fax:
Practice Address - Street 1:112 W CITRUS ST
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPG
Practice Address - State:FL
Practice Address - Zip Code:32714-2502
Practice Address - Country:US
Practice Address - Phone:407-865-5642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLS181712355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty