Healthcare Provider Details

I. General information

NPI: 1639346281
Provider Name (Legal Business Name): LAURA THORBURN MA CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11938 GOSHEN AVE APT 9
LOS ANGELES CA
90049-6320
US

IV. Provider business mailing address

11938 GOSHEN AVE APT 9
LOS ANGELES CA
90049-6320
US

V. Phone/Fax

Practice location:
  • Phone: 310-712-1281
  • Fax:
Mailing address:
  • Phone: 310-712-1281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP.14232
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP10088
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA18396
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: