1437606555 NPI number — TUSTIN SPEECH THERAPY, INC.

Table of content: (NPI 1629191226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437606555 NPI number — TUSTIN SPEECH THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TUSTIN SPEECH THERAPY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1437606555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 PARMA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-730-4859
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
661 WEST FIRST STREET
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-838-2853
Provider Business Practice Location Address Fax Number:
714-838-4533
Provider Enumeration Date:
09/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
FOWLER
Authorized Official First Name:
KYMRY
Authorized Official Middle Name:
HART
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-838-2853

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SP 10386 , 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: 09116318 . This is a "ASHA CCC-SLP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: SP 10386 . This is a "STATE OF CALIFORNIA - DCA - SPEECH/LANGUAGE PATHOLOGY LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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