Provider Demographics
NPI:1215226899
Name:DETTMER, CHRISTA (SLP)
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:
Last Name:DETTMER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 N. 67TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-4517
Mailing Address - Country:US
Mailing Address - Phone:623-691-4085
Mailing Address - Fax:623-691-5924
Practice Address - Street 1:3401 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-4517
Practice Address - Country:US
Practice Address - Phone:623-691-4085
Practice Address - Fax:623-691-5924
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP7073235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist