Healthcare Provider Details

I. General information

NPI: 1750104683
Provider Name (Legal Business Name): AUTUMN JEAN MARIE VERDUGO-SANDERLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 E ADOBE ST
MESA AZ
85213-6713
US

IV. Provider business mailing address

647 W BASELINE RD UNIT 1086
TEMPE AZ
85283-5063
US

V. Phone/Fax

Practice location:
  • Phone: 480-472-9800
  • Fax:
Mailing address:
  • Phone: 928-587-6118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA15569
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: