Healthcare Provider Details

I. General information

NPI: 1750624730
Provider Name (Legal Business Name): CENTER FOR DEVELOPING KIDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E DEL MAR BLVD SUITE 112
PASADENA CA
91105-2544
US

IV. Provider business mailing address

200 E DEL MAR BLVD SUITE 112
PASADENA CA
91105-2544
US

V. Phone/Fax

Practice location:
  • Phone: 626-564-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberRPE LICENSE #8148
License Number StateCA

VIII. Authorized Official

Name: KOURI SIMON
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential:
Phone: 626-564-2700