Provider Demographics
NPI:1467571273
Name:FLORENTINE, MARK F (MS CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:F
Last Name:FLORENTINE
Suffix:
Gender:M
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 1:4502 E JAEGER RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-6836
Mailing Address - Country:US
Mailing Address - Phone:480-473-1028
Mailing Address - Fax:
Practice Address - Street 1:20402 N 15TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3636
Practice Address - Country:US
Practice Address - Phone:623-445-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0640235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist