Provider Demographics
NPI:1972712685
Name:STOTZ, DEEANN (SLP)
Entity type:Individual
Prefix:
First Name:DEEANN
Middle Name:
Last Name:STOTZ
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 1:109 CREEKSIDE VLG
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-4514
Mailing Address - Country:US
Mailing Address - Phone:505-334-7383
Mailing Address - Fax:
Practice Address - Street 1:310 LA JARA ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-6626
Practice Address - Country:US
Practice Address - Phone:505-634-3868
Practice Address - Fax:505-634-3856
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1761235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP5847Medicaid