Provider Demographics
NPI:1063897122
Name:DESOTO, ALLIEJANE BOAZ
Entity type:Individual
Prefix:
First Name:ALLIEJANE
Middle Name:BOAZ
Last Name:DESOTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALLIEJANE
Other - Middle Name:
Other - Last Name:BOAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2386
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-2386
Mailing Address - Country:US
Mailing Address - Phone:928-226-1563
Mailing Address - Fax:
Practice Address - Street 1:101 S AIRPARK RD
Practice Address - Street 2:SUITE M
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4182
Practice Address - Country:US
Practice Address - Phone:928-639-2694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA94982355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant