Healthcare Provider Details

I. General information

NPI: 1609593417
Provider Name (Legal Business Name): KELLY ANN GUEVARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 S RURAL RD
TEMPE AZ
85282-3853
US

IV. Provider business mailing address

3750 BAYCHESTER AVE
BRONX NY
10466-5036
US

V. Phone/Fax

Practice location:
  • Phone: 480-730-7100
  • Fax:
Mailing address:
  • Phone: 718-515-6780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA13895
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number034204
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: