Provider Demographics
NPI:1336631852
Name:ACEVEDO-BANUELOS, LUZMARIA (SLPA)
Entity type:Individual
Prefix:
First Name:LUZMARIA
Middle Name:
Last Name:ACEVEDO-BANUELOS
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 1:6239 W WINDSOR BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-7306
Mailing Address - Country:US
Mailing Address - Phone:623-206-1541
Mailing Address - Fax:
Practice Address - Street 1:20329 N 59TH AVE STE A2
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6854
Practice Address - Country:US
Practice Address - Phone:623-500-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA110692355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLPA11069OtherARIZONA DEPARTMENT OF HEALTH SERVICES