Provider Demographics
NPI:1750517181
Name:LUNA-TAVARES, ALICE VIRGINIA (MA)
Entity type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:VIRGINIA
Last Name:LUNA-TAVARES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 ARLINGTON AVE
Mailing Address - Street 2:APT.# 5H
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-1503
Mailing Address - Country:US
Mailing Address - Phone:347-427-4845
Mailing Address - Fax:
Practice Address - Street 1:5700 ARLINGTON AVE
Practice Address - Street 2:APT.# 5H
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-1503
Practice Address - Country:US
Practice Address - Phone:347-427-4845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011505-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist