Provider Demographics
NPI:1659636660
Name:LASALLE, MARIA C (SLP)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:C
Last Name:LASALLE
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 1:412 HARBOR WINDS CT
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-5700
Mailing Address - Country:US
Mailing Address - Phone:407-325-7736
Mailing Address - Fax:
Practice Address - Street 1:7205 ALOMA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-7101
Practice Address - Country:US
Practice Address - Phone:321-972-3960
Practice Address - Fax:321-972-3960
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 11620235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist