Basic Information
| Provider Information | |||||||||
| NPI: | 1407065535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROVENCIO | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | HERIBERTHA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MA CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9898 N WINERY AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937205435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593237458 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936368761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593533000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 12864 | CA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.