Healthcare Provider Details

I. General information

NPI: 1811604689
Provider Name (Legal Business Name): LAURA MIOSOTIS TORRES AMADO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N LINCOLN ST STE A
DIXON CA
95620-3238
US

IV. Provider business mailing address

121 BRADLEY BLVD
TRAVIS AFB CA
94535-1344
US

V. Phone/Fax

Practice location:
  • Phone: 939-244-0208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number19042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: