Provider Demographics
NPI:1073775136
Name:KUNDE, MARISA (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:KUNDE
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:IRWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,CCC-SLP
Mailing Address - Street 1:551 S HIGLEY RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2148
Mailing Address - Country:US
Mailing Address - Phone:480-892-9777
Mailing Address - Fax:480-635-0222
Practice Address - Street 1:551 S HIGLEY RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2148
Practice Address - Country:US
Practice Address - Phone:480-892-9777
Practice Address - Fax:480-635-0222
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP5872235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ345176Medicaid