Basic Information
| Provider Information | |||||||||
| NPI: | 1639396286 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPEECH LANGUAGE PATHOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12791 NEWPORT AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927802751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145441860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12791 NEWPORT AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927802751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145441860 | ||||||||
| FaxNumber: | 7147305372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | SWITZER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER, SPEECH PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7145441860 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | SP 3165 | CA | Y | Agencies | Early Intervention Provider Agency |
ID Information
| ID | Type | State | Issuer | Description | 0031650 | 01 | CA | BLUE SHIELD | OTHER | SP31650 | 01 | CA | BLUE CROSS | OTHER |