Basic Information
| Provider Information | |||||||||
| NPI: | 1568940088 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUENROSTRO | ||||||||
| FirstName: | NICOLETTE | ||||||||
| MiddleName: | CHANTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 W 6TH ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171823 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 W 6TH ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136074400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2018 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 12606 | CA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 28526 | CA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.