Healthcare Provider Details

I. General information

NPI: 1184112757
Provider Name (Legal Business Name): GENERATION SPEECH THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2018
Last Update Date: 04/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11150 BERTRAND AVE
GRANADA HILLS CA
91344-4005
US

IV. Provider business mailing address

11150 BERTRAND AVE
GRANADA HILLS CA
91344-4005
US

V. Phone/Fax

Practice location:
  • Phone: 818-915-1966
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHANNON BROUSSALIAN
Title or Position: OWNER/SPEECH-LANGAUGE PATHOLOGIST
Credential: M.S., CCC-SLP
Phone: 818-915-1966