Healthcare Provider Details

I. General information

NPI: 1689398067
Provider Name (Legal Business Name): ROSA M AGUALLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 N WASHINGTON AVE
DOUGLAS AZ
85607-3602
US

IV. Provider business mailing address

PO BOX 163
ELFRIDA AZ
85610-0163
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-6311
  • Fax:
Mailing address:
  • Phone: 520-508-5193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA7405
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: