Healthcare Provider Details

I. General information

NPI: 1679723191
Provider Name (Legal Business Name): ELITE SPEECH PATHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2008
Last Update Date: 09/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 W PAMPA AVE
MESA AZ
85202-8013
US

IV. Provider business mailing address

1806 W PAMPA AVE
MESA AZ
85202-8013
US

V. Phone/Fax

Practice location:
  • Phone: 480-612-7362
  • Fax: 480-393-3670
Mailing address:
  • Phone: 480-612-7362
  • Fax: 480-393-3670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberSLP4118
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberSLP4118
License Number StateAZ

VIII. Authorized Official

Name: TRACY ANN CONTRERAS
Title or Position: OWNER/CEO
Credential: M.S. CCC SLP
Phone: 480-612-7362