Provider Demographics
NPI:1457769887
Name:RICCA, MATTHEW A (TSLP)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:RICCA
Suffix:
Gender:M
Credentials:TSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 E BROADWAY BLVD
Mailing Address - Street 2:SUITE SUITE 124-143
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-5966
Mailing Address - Country:US
Mailing Address - Phone:520-232-2021
Mailing Address - Fax:520-223-2553
Practice Address - Street 1:5200 E FARNESS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2140
Practice Address - Country:US
Practice Address - Phone:520-232-2021
Practice Address - Fax:520-232-2553
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP8922235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist