1801019773 NPI number — SPEECH PATHOLOGY SERVICES OF MARIN SONOMA INCORPORTATED

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 1801019773 NPI number — SPEECH PATHOLOGY SERVICES OF MARIN SONOMA INCORPORTATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPEECH PATHOLOGY SERVICES OF MARIN SONOMA INCORPORTATED
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:
1801019773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 REDWOOD WAY
Provider Second Line Business Mailing Address:
SUITE 165
Provider Business Mailing Address City Name:
PETALUMA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94954-1107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-763-6419
Provider Business Mailing Address Fax Number:
707-763-2537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 REDWOOD WAY
Provider Second Line Business Practice Location Address:
SUITE 165
Provider Business Practice Location Address City Name:
PETALUMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94954-1107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-763-6419
Provider Business Practice Location Address Fax Number:
707-763-2537
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STEVICK
Authorized Official First Name:
ELAINE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO CLINICAL DIRECTOR
Authorized Official Telephone Number:
707-763-6419

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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