Healthcare Provider Details

I. General information

NPI: 1932757895
Provider Name (Legal Business Name): JAY RICHARD HARVEY SLPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 FOOTHILLS DR
FARMINGTON NM
87402-8279
US

IV. Provider business mailing address

5804 ARROYO DR
FARMINGTON NM
87402-5008
US

V. Phone/Fax

Practice location:
  • Phone: 505-599-8604
  • Fax:
Mailing address:
  • Phone: 303-709-1449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA6143
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: