Provider Demographics
NPI:1487396792
Name:ESTEVEZ, VADIA
Entity type:Individual
Prefix:
First Name:VADIA
Middle Name:
Last Name:ESTEVEZ
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 1:1101 MIRANDA LN STE 127
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-0771
Mailing Address - Country:US
Mailing Address - Phone:321-300-9077
Mailing Address - Fax:321-291-5124
Practice Address - Street 1:1101 MIRANDA LN STE 127
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-0771
Practice Address - Country:US
Practice Address - Phone:321-300-9077
Practice Address - Fax:321-291-5124
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-08
Last Update Date:2024-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL113497700251C00000X
251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113497700Medicaid