MEDICARE: NORIKO MIZUHARA 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	SP 19346	CA

General Provider Information

NPI Number	:	1801169644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NORIKO MIZUHARA CCC-SLP

Provider Business Mailing Address
First Line	:	11381 MOUNT WALLACE CT
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91737-6557
Country	:	US
Telephone Number	:	909-944-8411
Fax Number	:	909-608-0088

Provider Business Practice Location Address
First Line	:	11381 MOUNT WALLACE CT
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91737-6557
Country	:	US
Telephone Number	:	909-944-8411
Fax Number	:	909-608-0088

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

Provider Enumeration Date	:	02/09/2012
Last Update Date	:	02/09/2012

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Directions to “ NORIKO MIZUHARA CCC-SLP” Practice Location

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