Provider Demographics
NPI:1104358175
Name:DIVINAGRACIA, EVELYN (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:
Last Name:DIVINAGRACIA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1262 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-7405
Mailing Address - Country:US
Mailing Address - Phone:310-971-5754
Mailing Address - Fax:
Practice Address - Street 1:3002 DOW AVE
Practice Address - Street 2:114
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7233
Practice Address - Country:US
Practice Address - Phone:714-731-4668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18689235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist