Healthcare Provider Details

I. General information

NPI: 1861309403
Provider Name (Legal Business Name): CHELSEY KWAK
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18870 JURUPA AVE
BLOOMINGTON CA
92316-3100
US

IV. Provider business mailing address

850 E WASHINGTON ST
COLTON CA
92324-8101
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-5010
  • Fax:
Mailing address:
  • Phone: 909-580-5002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number33281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: