Healthcare Provider Details

I. General information

NPI: 1154190882
Provider Name (Legal Business Name): CAROLYN AGBIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 W 190TH ST STE 2300
GARDENA CA
90248-4350
US

IV. Provider business mailing address

2553 SEABRIGHT AVE
LONG BEACH CA
90810-3252
US

V. Phone/Fax

Practice location:
  • Phone: 310-892-5812
  • Fax:
Mailing address:
  • Phone: 562-773-3757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number8067
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: