MEDICARE: PHUONG T DEBELLIS M.S. CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	18370	CA

General Provider Information

NPI Number	:	1053814988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHUONG T DEBELLIS M.S. CCC-SLP

Provider Business Mailing Address
First Line	:	3218 ROOSEVELT AVE
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94804-1548
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3218 ROOSEVELT AVE
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94804-1548
Country	:	US
Telephone Number	:	209-814-7564
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2018
Last Update Date	:	07/07/2021

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