Healthcare Provider Details

I. General information

NPI: 1619533494
Provider Name (Legal Business Name): SPARKLE 'WHERE OUR VOICES SHINE' INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W BASELINE RD STE D
GLENDORA CA
91740-4817
US

IV. Provider business mailing address

420 W BASELINE RD STE E
GLENDORA CA
91740-4817
US

V. Phone/Fax

Practice location:
  • Phone: 626-594-5409
  • Fax:
Mailing address:
  • Phone: 626-594-5409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: KEAUNNA S KNOX
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 626-594-5409