Basic Information
Provider Information | |||||||||
NPI: | 1780810374 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONSTANZO | ||||||||
FirstName: | DANIELLE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 933 BRADBURY DR SE | ||||||||
Address2: | SUITE 2222 | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871064374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052723120 | ||||||||
FaxNumber: | 5052728060 | ||||||||
Practice Location | |||||||||
Address1: | 5200 COPPER AVE NE | ||||||||
Address2: | #A | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871081473 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052665557 | ||||||||
FaxNumber: | 5052665545 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2009 | ||||||||
LastUpdateDate: | 02/22/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 104277 | TX | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 5528 | NM | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 17593 | CA | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.