Provider Demographics
NPI:1538266895
Name:GOLDEN, JANELLE MARIE (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:JANELLE
Middle Name:MARIE
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2943
Mailing Address - Street 2:3747 EAST BERMUDA CIRCLE
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-2943
Mailing Address - Country:US
Mailing Address - Phone:928-369-3466
Mailing Address - Fax:
Practice Address - Street 1:294 W. CARLOS
Practice Address - Street 2:SPECIAL SERVICES CONSORTIUM
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025
Practice Address - Country:US
Practice Address - Phone:928-524-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP003235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLP0003OtherSTATE LICENSE NUMBER
AZ585953Medicaid