Provider Demographics
NPI:1437521572
Name:FONDEVILLA-PEREZ, MAUREEN J (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:J
Last Name:FONDEVILLA-PEREZ
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 1:210 N CENTRAL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2536
Mailing Address - Country:US
Mailing Address - Phone:818-245-6718
Mailing Address - Fax:818-245-6719
Practice Address - Street 1:210 N CENTRAL AVE STE 200
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2536
Practice Address - Country:US
Practice Address - Phone:818-245-6718
Practice Address - Fax:818-245-6719
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15483235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist