Provider Demographics
NPI:1760784672
Name:PEDRO, IMELDA
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:
Last Name:PEDRO
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 1:1224 S 41ST DR
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1224 S 41ST DR
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4075
Practice Address - Country:US
Practice Address - Phone:928-210-2339
Practice Address - Fax:928-726-9058
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA70172355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant