Provider Demographics
NPI:1851676787
Name:REBOUL, MONICA LEIGH (MA,SLP)
Entity Type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:LEIGH
Last Name:REBOUL
Suffix:
Gender:F
Credentials:MA,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 HAINES AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2638
Mailing Address - Country:US
Mailing Address - Phone:505-504-8910
Mailing Address - Fax:
Practice Address - Street 1:8100 RAINBOW BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-6090
Practice Address - Country:US
Practice Address - Phone:505-890-0343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4869235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNONE ASSIGNEDMedicaid