Healthcare Provider Details

I. General information

NPI: 1790692523
Provider Name (Legal Business Name): ADYLENNE DE LA TORRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22751 MAIN ST
SAN LUIS AZ
85349
US

IV. Provider business mailing address

PO BOX 2742
SAN LUIS AZ
85349-2742
US

V. Phone/Fax

Practice location:
  • Phone: 928-627-6960
  • Fax:
Mailing address:
  • Phone: 928-304-9675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA15112
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: