Healthcare Provider Details

I. General information

NPI: 1508849571
Provider Name (Legal Business Name): DANIELLE BALTAZAR M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 CULVER BLVD #112
PLAYA DEL REY CA
90293-7767
US

IV. Provider business mailing address

405 CULVER BLVD #112
PLAYA DEL REY CA
90293-7769
US

V. Phone/Fax

Practice location:
  • Phone: 310-403-4015
  • Fax:
Mailing address:
  • Phone: 310-403-4015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: