=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568299063
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANEY ANDREA GRIJALVA BS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2024
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1132 E 12TH ST
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85607-2337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-364-2447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2714 E 6TH ST
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85607-3526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-236-8956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | SLPA15699
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------