Provider Demographics
NPI:1689398067
Name:AGUALLO, ROSA M
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:M
Last Name:AGUALLO
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:PO BOX 163
Mailing Address - Street 2:
Mailing Address - City:ELFRIDA
Mailing Address - State:AZ
Mailing Address - Zip Code:85610-0163
Mailing Address - Country:US
Mailing Address - Phone:520-508-5193
Mailing Address - Fax:
Practice Address - Street 1:3715 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-3602
Practice Address - Country:US
Practice Address - Phone:520-364-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA74052355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant