MEDICARE: EXTENSIVE THERAPY CONNECTION AND SOLUTION

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	251300000X	Local Education Agency (LEA)	14383	CA
2	251300000X	Local Education Agency (LEA)	14361	CA

General Provider Information

NPI Number	:	1689967630
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTENSIVE THERAPY CONNECTION AND SOLUTION

Provider Business Mailing Address
First Line	:	1618 FOX GLEN DR
Second Line	:
City	:	DIAMOND BAR
State	:	CA
Zip	:	91765-2929
Country	:	US
Telephone Number	:	951-332-7832
Fax Number	:

Provider Business Practice Location Address
First Line	:	1618 FOX GLEN DR
Second Line	:
City	:	DIAMOND BAR
State	:	CA
Zip	:	91765-2929
Country	:	US
Telephone Number	:	951-332-7832
Fax Number	:

Authorized Official
Title or Position	:	SPEECH AND LANGUAGE PATHOLOGIST
Name	:	MR. SAWMICK DUTTA
Credential	:	MS
Telephone Number	:	951-332-7832

Provider Enumeration Date	:	05/24/2011
Last Update Date	:	05/24/2011

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Directions to “EXTENSIVE THERAPY CONNECTION AND SOLUTION ” Practice Location

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