Provider Demographics
NPI:1720506710
Name:DECOSTA, ALYCEN FIELDING (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALYCEN
Middle Name:FIELDING
Last Name:DECOSTA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-2449
Mailing Address - Country:US
Mailing Address - Phone:435-231-4112
Mailing Address - Fax:
Practice Address - Street 1:397 S 200 E
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660
Practice Address - Country:US
Practice Address - Phone:801-210-9319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10144790-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist