Provider Demographics
NPI:1417605817
Name:NEVALA, ADELINE ROSE
Entity Type:Individual
Prefix:
First Name:ADELINE
Middle Name:ROSE
Last Name:NEVALA
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 1:16745 SW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-8001
Mailing Address - Country:US
Mailing Address - Phone:612-219-5983
Mailing Address - Fax:
Practice Address - Street 1:101 N POST RD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-3605
Practice Address - Country:US
Practice Address - Phone:405-397-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKSLPA270224Z00000X, 2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant