Provider Demographics
NPI:1174842892
Name:VAN DEN BOOM, ESPERANZA H (SPEECH PATHOLOGIST)
Entity Type:Individual
Prefix:MS
First Name:ESPERANZA
Middle Name:H
Last Name:VAN DEN BOOM
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18602 E OLD BEAU TRL
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-3518
Mailing Address - Country:US
Mailing Address - Phone:586-873-2359
Mailing Address - Fax:
Practice Address - Street 1:18602 E OLD BEAU TRL
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-3518
Practice Address - Country:US
Practice Address - Phone:586-873-2359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL 6680235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist