Basic Information
Provider Information | |||||||||
NPI: | 1447767348 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BANTEGUI | ||||||||
FirstName: | ASHLEY | ||||||||
MiddleName: | KRISTINE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | SLPA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1301 W PROVIDENCE AVE | ||||||||
Address2: |   | ||||||||
City: | ORANGE | ||||||||
State: | CA | ||||||||
PostalCode: | 928683892 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7146394990 | ||||||||
FaxNumber: | 7148443841 | ||||||||
Practice Location | |||||||||
Address1: | 12881 KNOTT ST STE 103 | ||||||||
Address2: |   | ||||||||
City: | GARDEN GROVE | ||||||||
State: | CA | ||||||||
PostalCode: | 928413939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148926828 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2018 | ||||||||
LastUpdateDate: | 04/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 2971 | CA | Y |   | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
No ID Information.