1215069117 NPI number — MICHELE SHERIE SERRANO MA CCC-SLP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215069117 NPI number — MICHELE SHERIE SERRANO MA CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SERRANO
Provider First Name:
MICHELE
Provider Middle Name:
SHERIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215069117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 W BROADWAY
Provider Second Line Business Mailing Address:
STE A540
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-247-1785
Provider Business Mailing Address Fax Number:
844-946-2985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1440 COLUMBIA ST APT 2001
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92101-3483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-866-8260
Provider Business Practice Location Address Fax Number:
844-946-2985
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  17150 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3108 . This is a "COLORADO DORA" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: SP 17150 . This is a "CALIFORNIA SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY BOARD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 117335 . This is a "TEXAS DEPT OF LICENSING AND REGULATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 12082520 . This is a "AMERICAN SPEECH & HEARING ASSOCIATION" identifier . This identifiers is of the category "OTHER".




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