Provider Demographics
NPI:1891363610
Name:DE LAVEAGA, SHARON H (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:H
Last Name:DE LAVEAGA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 WILDWOOD CT NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-2231
Mailing Address - Country:US
Mailing Address - Phone:503-409-4120
Mailing Address - Fax:
Practice Address - Street 1:3871 FAIRVIEW INDUSTRIAL DR SE STE 150
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1172
Practice Address - Country:US
Practice Address - Phone:503-926-4299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17129235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist