Provider Demographics
NPI:1912110032
Name:LITTLE SOLDIER, PATRICIA (MS-CCC/SLP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:LITTLE SOLDIER
Suffix:
Gender:F
Credentials:MS-CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7805 COORS BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-7307
Mailing Address - Country:US
Mailing Address - Phone:505-389-9243
Mailing Address - Fax:
Practice Address - Street 1:4210 SABANA GRANDE AVE SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1152
Practice Address - Country:US
Practice Address - Phone:505-892-6603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101119235Z00000X
NM6705235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197084001Medicaid
NM1912110032OtherSLP LICENSE