Provider Demographics
NPI:1578003414
Name:FOGLESONG, SHAYNA
Entity Type:Individual
Prefix:
First Name:SHAYNA
Middle Name:
Last Name:FOGLESONG
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 1:6002 W MONTE CRISTO AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-2313
Mailing Address - Country:US
Mailing Address - Phone:602-677-2669
Mailing Address - Fax:
Practice Address - Street 1:6002 W MONTE CRISTO AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-2313
Practice Address - Country:US
Practice Address - Phone:602-677-2669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-25
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA104842355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant