Provider Demographics
NPI:1023249323
Name:ARIZONA SPEECH PATHOLOGY
Entity type:Organization
Organization Name:ARIZONA SPEECH PATHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRISH
Authorized Official - Middle Name:J
Authorized Official - Last Name:NEDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:480-451-7226
Mailing Address - Street 1:2435 E SOUTHERN AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7628
Mailing Address - Country:US
Mailing Address - Phone:480-451-7226
Mailing Address - Fax:
Practice Address - Street 1:2435 E SOUTHERN AVE STE 7
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7628
Practice Address - Country:US
Practice Address - Phone:480-451-7226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 252Y00000X
AZE2106133235Z00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ401703Medicaid