Provider Demographics
NPI:1669969598
Name:CHISUM, DIANA (SLPA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CHISUM
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 N 110TH DR
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-5892
Mailing Address - Country:US
Mailing Address - Phone:623-229-9423
Mailing Address - Fax:
Practice Address - Street 1:2629 N 110TH DR
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5892
Practice Address - Country:US
Practice Address - Phone:623-229-9423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA110632355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant