Healthcare Provider Details

I. General information

NPI: 1902442130
Provider Name (Legal Business Name): STACY GOLDEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 N VERDUGO RD APT 37
GLENDALE CA
91208-2834
US

IV. Provider business mailing address

1550 N VERDUGO RD APT 37
GLENDALE CA
91208-2834
US

V. Phone/Fax

Practice location:
  • Phone: 805-216-5604
  • Fax:
Mailing address:
  • Phone: 805-216-5604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STACY GOLDEN
Title or Position: OWNER/PROVIDER
Credential: MS, CCC-SLP
Phone: 805-216-5604