Provider Demographics
NPI:1720262595
Name:ROLDAN, MAYRA B (SLP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:B
Last Name:ROLDAN
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 AYITO RD SE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-5983
Mailing Address - Country:US
Mailing Address - Phone:703-725-8251
Mailing Address - Fax:
Practice Address - Street 1:322 AYITO RD SE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-5983
Practice Address - Country:US
Practice Address - Phone:703-725-8251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005217235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist