Provider Demographics
NPI:1093382699
Name:VISENTIN, MIKA (SLPA)
Entity Type:Individual
Prefix:MRS
First Name:MIKA
Middle Name:
Last Name:VISENTIN
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 W GLENN DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-2628
Mailing Address - Country:US
Mailing Address - Phone:623-915-0345
Mailing Address - Fax:
Practice Address - Street 1:5430 W GLENN DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-2628
Practice Address - Country:US
Practice Address - Phone:623-915-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA108002355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant