Healthcare Provider Details

I. General information

NPI: 1629520192
Provider Name (Legal Business Name): MICHELE JEAN SAN ANTONIO M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S BEAUDRY AVE
LOS ANGELES CA
90017-1466
US

IV. Provider business mailing address

4334 MATILIJA AVE APT 220
SHERMAN OAKS CA
91423-3625
US

V. Phone/Fax

Practice location:
  • Phone: 213-241-6200
  • Fax:
Mailing address:
  • Phone: 401-269-9410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP 13836
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: