Provider Demographics
NPI:1396791141
Name:DIPUCCIO, ADAM (CCC-AFAAA)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:DIPUCCIO
Suffix:
Gender:M
Credentials:CCC-AFAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5202 E. MAIN ST.
Mailing Address - Street 2:SUITE #105
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-8038
Mailing Address - Country:US
Mailing Address - Phone:480-218-1328
Mailing Address - Fax:480-218-1330
Practice Address - Street 1:5202 E. MAIN ST.
Practice Address - Street 2:SUITE #105
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8038
Practice Address - Country:US
Practice Address - Phone:480-218-1328
Practice Address - Fax:480-218-1330
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA2043231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ894164Medicaid
1396791141OtherINDIVIDUAL NPI
AZDA2043OtherSTATE AUDIOLOGY LIC #
1881708261OtherGROUP NPI
Y16021OtherGROUP UPIN
1881708261OtherGROUP NPI
Y16021OtherGROUP UPIN
AZQ22122Medicare UPIN
AZ894164Medicaid