Provider Demographics
NPI:1568810307
Name:NGON, ANNIE
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:NGON
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 1:628 BOOTLEG RD
Mailing Address - Street 2:
Mailing Address - City:CLARKDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:86324-3326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:628 BOOTLEG RD
Practice Address - Street 2:
Practice Address - City:CLARKDALE
Practice Address - State:AZ
Practice Address - Zip Code:86324-3326
Practice Address - Country:US
Practice Address - Phone:928-254-8059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA9767235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist