Healthcare Provider Details

I. General information

NPI: 1568299063
Provider Name (Legal Business Name): DIANEY ANDREA GRIJALVA BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 E 12TH ST
DOUGLAS AZ
85607-2337
US

IV. Provider business mailing address

2714 E 6TH ST
DOUGLAS AZ
85607-3526
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-2447
  • Fax:
Mailing address:
  • Phone: 520-236-8956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA15699
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: