Provider Demographics
NPI:1841554417
Name:VAN DINTEREN, MONICA (SLP)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:VAN DINTEREN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 E CONSTANCE WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-0012
Mailing Address - Country:US
Mailing Address - Phone:856-816-7181
Mailing Address - Fax:
Practice Address - Street 1:3421 E CONSTANCE WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-0012
Practice Address - Country:US
Practice Address - Phone:856-816-7181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP7809235Z00000X
AZTSLP7809235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ711458Medicaid