Provider Demographics
NPI:1972099703
Name:DE AYORA, LUCAS M (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:M
Last Name:DE AYORA
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 E I ST
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-3576
Mailing Address - Country:US
Mailing Address - Phone:909-856-6744
Mailing Address - Fax:
Practice Address - Street 1:144 CONTINENTE AVE STE 100
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-7102
Practice Address - Country:US
Practice Address - Phone:925-513-2440
Practice Address - Fax:925-513-2470
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20129235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist