Provider Demographics
NPI:1548923337
Name:KISANGA, EDITH (SLP-CCC)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:KISANGA
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9150 W INDIAN SCHOOL RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-2388
Mailing Address - Country:US
Mailing Address - Phone:480-787-5387
Mailing Address - Fax:
Practice Address - Street 1:1016 W UNIVERSITY AVE STE 220
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-2997
Practice Address - Country:US
Practice Address - Phone:480-787-5387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.13966235Z00000X
CA37724235Z00000X
AZSLP15979235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist