Healthcare Provider Details

I. General information

NPI: 1881969673
Provider Name (Legal Business Name): MANJU MARIN CHACKO CCC - SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 RELIANT WAY
AMERICAN CANYON CA
94503-3236
US

IV. Provider business mailing address

227 RELIANT WAY
AMERICAN CANYON CA
94503-3236
US

V. Phone/Fax

Practice location:
  • Phone: 626-321-7296
  • Fax:
Mailing address:
  • Phone: 626-321-7296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number17280
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number103308
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: