Provider Demographics
NPI:1750755120
Name:CORDOVA, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11360 183RD ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-5419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 HIGHWAY 95 N STE 308C5601
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86404-8536
Practice Address - Country:US
Practice Address - Phone:928-854-5439
Practice Address - Fax:928-854-5440
Is Sole Proprietor?:No
Enumeration Date:2015-11-21
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPE10068235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist