Provider Demographics
NPI:1578949319
Name:MAIAVA, ASHLEY ELIZABETH (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ELIZABETH
Last Name:MAIAVA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ELIZABETH
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:539 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MO
Mailing Address - Zip Code:64098
Mailing Address - Country:US
Mailing Address - Phone:620-532-1692
Mailing Address - Fax:
Practice Address - Street 1:539 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:MO
Practice Address - Zip Code:64098
Practice Address - Country:US
Practice Address - Phone:620-532-1692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3736235Z00000X
MO2015028354235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist