Healthcare Provider Details

I. General information

NPI: 1124171020
Provider Name (Legal Business Name): MRS. NELLY TERESA ANTICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NELLY CANAR SLP

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S GRAND AVE
LOS ANGELES CA
90015-3010
US

IV. Provider business mailing address

2307 VALLEY DR
HERMOSA BEACH CA
90254-2650
US

V. Phone/Fax

Practice location:
  • Phone: 213-742-5568
  • Fax:
Mailing address:
  • Phone: 310-376-7735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5790
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: