Healthcare Provider Details

I. General information

NPI: 1720661739
Provider Name (Legal Business Name): JULYSSA AIDEE HERNANDEZ SLPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 E SOUTHERN AVE
MESA AZ
85204-5409
US

IV. Provider business mailing address

6152 W OAKLAND ST APT 201
CHANDLER AZ
85226-2613
US

V. Phone/Fax

Practice location:
  • Phone: 480-361-1972
  • Fax:
Mailing address:
  • Phone: 928-919-2819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA12996
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: