Provider Demographics
NPI:1801389630
Name:DE LA TORRE, ELYSA RENEE (SLPA)
Entity type:Individual
Prefix:
First Name:ELYSA
Middle Name:RENEE
Last Name:DE LA TORRE
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 1:1830 E BROADWAY BLVD STE 124-143
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-5966
Mailing Address - Country:US
Mailing Address - Phone:520-232-2021
Mailing Address - Fax:520-232-2553
Practice Address - Street 1:1830 E BROADWAY BLVD STE 124-143
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-5966
Practice Address - Country:US
Practice Address - Phone:520-232-2021
Practice Address - Fax:520-232-2553
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1110502355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant