Provider Demographics
NPI:1134559230
Name:DESONNAVILLE, TANIA E
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:E
Last Name:DESONNAVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANIA
Other - Middle Name:E
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11860 W SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-9124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11951 W OVERLIN LN
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-7723
Practice Address - Country:US
Practice Address - Phone:602-384-8818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA86182355S0801X
CASP35258235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant