Provider Demographics
NPI:1265034706
Name:DISHEVA, MARIA NIKOLOVA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:NIKOLOVA
Last Name:DISHEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3814 E REGENTS CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7131
Mailing Address - Country:US
Mailing Address - Phone:808-979-5502
Mailing Address - Fax:
Practice Address - Street 1:2010 S YOST AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3188
Practice Address - Country:US
Practice Address - Phone:812-822-0605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22007613A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist