Provider Demographics
NPI:1003950767
Name:DONG, LORI A (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:DONG
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4833 E EARLL DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-6561
Mailing Address - Country:US
Mailing Address - Phone:602-957-3884
Mailing Address - Fax:
Practice Address - Street 1:3401 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-4517
Practice Address - Country:US
Practice Address - Phone:623-691-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4388235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ877649Medicaid