Healthcare Provider Details

I. General information

NPI: 1407065535
Provider Name (Legal Business Name): MARIA HERIBERTHA PROVENCIO MA CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8761
US

IV. Provider business mailing address

9898 N WINERY AVE
FRESNO CA
93720-5435
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-3000
  • Fax:
Mailing address:
  • Phone: 559-323-7458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12864
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: