Healthcare Provider Details

I. General information

NPI: 1124315221
Provider Name (Legal Business Name): B EXPRESSIVE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2011
Last Update Date: 07/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 CENTER DR W STE. #540
LOS ANGELES CA
90045-1582
US

IV. Provider business mailing address

6601 CENTER DR W STE. #540
LOS ANGELES CA
90045-1582
US

V. Phone/Fax

Practice location:
  • Phone: 310-766-4747
  • Fax: 310-337-1379
Mailing address:
  • Phone: 310-766-4747
  • Fax: 310-337-1379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP8247
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License NumberSP8247
License Number StateCA

VIII. Authorized Official

Name: MS. BRENDA RENA DEADWYLER
Title or Position: CEO/SPEECH PATHOLOGIST
Credential: LIC. MHSCCCSLP
Phone: 310-766-4747