Provider Demographics
NPI:1508055070
Name:TSURUSAKI, MARY KEVIN (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KEVIN
Last Name:TSURUSAKI
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 1:6160 N PANORAMA CIR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-2853
Mailing Address - Country:US
Mailing Address - Phone:520-229-8992
Mailing Address - Fax:
Practice Address - Street 1:RED ROCK ELEMENTARY SCHOOL
Practice Address - Street 2:33656 W AGUIRRE LN
Practice Address - City:RED ROCK
Practice Address - State:AZ
Practice Address - Zip Code:85245
Practice Address - Country:US
Practice Address - Phone:520-682-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0724235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ114970Medicaid