Provider Demographics
NPI:1750629952
Name:GERMAINE, DUSTIN M
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:M
Last Name:GERMAINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 E PONCHO LN
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-3218
Mailing Address - Country:US
Mailing Address - Phone:480-343-7124
Mailing Address - Fax:
Practice Address - Street 1:1462 E PONCHO LN
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-3218
Practice Address - Country:US
Practice Address - Phone:480-343-7124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA81512355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant