Basic Information
| Provider Information | |||||||||
| NPI: | 1437606555 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TUSTIN SPEECH THERAPY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 PARMA | ||||||||
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| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147304859 | ||||||||
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| Practice Location | |||||||||
| Address1: | 661 WEST FIRST STREET | ||||||||
| Address2: | SUITE E | ||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148382853 | ||||||||
| FaxNumber: | 7148384533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2016 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | FOWLER | ||||||||
| AuthorizedOfficialFirstName: | KYMRY | ||||||||
| AuthorizedOfficialMiddleName: | HART | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7148382853 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MA, CCC, SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP 10386 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 09116318 | 01 | CA | ASHA CCC-SLP | OTHER | SP 10386 | 01 | CA | STATE OF CALIFORNIA - DCA - SPEECH/LANGUAGE PATHOLOGY LICENSE | OTHER |