Basic Information
| Provider Information | |||||||||
| NPI: | 1306257548 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TUSTIN SPEECH THERAPY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 661 W 1ST ST STE E | ||||||||
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| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927802939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148382853 | ||||||||
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| Address1: | 661 W 1ST ST STE E | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927802939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148382853 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2014 | ||||||||
| LastUpdateDate: | 05/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | FOWLER | ||||||||
| AuthorizedOfficialFirstName: | KYMRY | ||||||||
| AuthorizedOfficialMiddleName: | HART | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7148382853 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MS-CCC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 2634 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 225X00000X | 722 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XP0200X | 722 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 2355S0801X | 655 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | 235Z00000X | 17425 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 0050430 | 05 | CA | MEDICAID |