Provider Demographics
NPI:1871758946
Name:KELLENBERGER, EUGENIA VASILAKOS (MA CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:EUGENIA
Middle Name:VASILAKOS
Last Name:KELLENBERGER
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:MS
Other - First Name:EUGENIA
Other - Middle Name:
Other - Last Name:VASILAKOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22253 N 102ND LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-2656
Mailing Address - Country:US
Mailing Address - Phone:480-335-4261
Mailing Address - Fax:
Practice Address - Street 1:22253 N 102ND LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2656
Practice Address - Country:US
Practice Address - Phone:480-335-4261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8948235Z00000X
CASP15208235Z00000X
AZSLP5829235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist