Provider Demographics
NPI:1952522344
Name:DETHOMASIS, BETTY
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:DETHOMASIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12479 W PALM LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-6400
Mailing Address - Country:US
Mailing Address - Phone:914-490-7728
Mailing Address - Fax:
Practice Address - Street 1:12479 W PALM LN
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-6400
Practice Address - Country:US
Practice Address - Phone:914-490-7728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP5169235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist