Basic Information
Provider Information | |||||||||
NPI: | 1326569195 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FELIX | ||||||||
FirstName: | JO | ||||||||
MiddleName: | ELLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S. CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ANDERSEN | ||||||||
OtherFirstName: | JO | ||||||||
OtherMiddleName: | ELLEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.S CCC-SLP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1450 TREAT BLVD STE 300 | ||||||||
Address2: |   | ||||||||
City: | WALNUT CREEK | ||||||||
State: | CA | ||||||||
PostalCode: | 945972168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9259522828 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 350 JOHN MUIR PKWY STE 250 | ||||||||
Address2: |   | ||||||||
City: | BRENTWOOD | ||||||||
State: | CA | ||||||||
PostalCode: | 945135194 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9253088636 | ||||||||
FaxNumber: | 9253088760 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2017 | ||||||||
LastUpdateDate: | 10/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 16687 | CA | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.