Healthcare Provider Details

I. General information

NPI: 1669382719
Provider Name (Legal Business Name): MAURICIO CARVAJAL VILLASENOR SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 S WALDRON RD
FORT SMITH AR
72903-3761
US

IV. Provider business mailing address

2220 S WALDRON RD
FORT SMITH AR
72903-3761
US

V. Phone/Fax

Practice location:
  • Phone: 479-434-2371
  • Fax:
Mailing address:
  • Phone: 479-434-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number203763
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: