Healthcare Provider Details

I. General information

NPI: 1508727181
Provider Name (Legal Business Name): MARY LOUISE NINAN M.A., M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY LOU NINAN M.A., M.S., CCC-SLP

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1252 SEVILLE DR
PACIFICA CA
94044-3554
US

IV. Provider business mailing address

1252 SEVILLE DR
PACIFICA CA
94044-3554
US

V. Phone/Fax

Practice location:
  • Phone: 415-412-1757
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number40461
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: