Provider Demographics
NPI:1164035705
Name:CORDOVA, DEANNA MARI (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:MARI
Last Name:CORDOVA
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 1:1517 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6928
Mailing Address - Country:US
Mailing Address - Phone:575-749-2711
Mailing Address - Fax:
Practice Address - Street 1:1517 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6928
Practice Address - Country:US
Practice Address - Phone:575-749-2711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSLP2972235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist