Healthcare Provider Details

I. General information

NPI: 1073752630
Provider Name (Legal Business Name): TERESA CARDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2009
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 S CABRIO TER
MESA AZ
85212-9671
US

IV. Provider business mailing address

4660 S CABRIO TER
MESA AZ
85212-9671
US

V. Phone/Fax

Practice location:
  • Phone: 509-251-0774
  • Fax:
Mailing address:
  • Phone: 509-251-0774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP4237
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number8420934-2506
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: