Provider Demographics
NPI:1669287579
Name:ASENCIO-ACEVEDO, IVANISSE CORALY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:IVANISSE
Middle Name:CORALY
Last Name:ASENCIO-ACEVEDO
Suffix:
Gender:
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 1:1502 S ORCHARD ST APT F304
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-2445
Mailing Address - Country:US
Mailing Address - Phone:334-470-6604
Mailing Address - Fax:
Practice Address - Street 1:1502 S ORCHARD ST APT F304
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-2445
Practice Address - Country:US
Practice Address - Phone:334-470-6604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-08
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60846550235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist