Provider Demographics
NPI:1710184411
Name:FRAGOSO, ANA MARIA (MS, CCC)
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:MARIA
Last Name:FRAGOSO
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 RIVERSIDE DR
Mailing Address - Street 2:APT 5
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-2920
Mailing Address - Country:US
Mailing Address - Phone:818-404-7854
Mailing Address - Fax:
Practice Address - Street 1:1621 RIVERSIDE DR
Practice Address - Street 2:APT 5
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-2920
Practice Address - Country:US
Practice Address - Phone:818-404-7854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13789235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist