Healthcare Provider Details

I. General information

NPI: 1720220817
Provider Name (Legal Business Name): DIRECT THERAPY, S&P
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2009
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 ROYALTY DRIVE, SUITE 210
POMONA CA
91767
US

IV. Provider business mailing address

265 W. SONORA PLACE
CLAREMONT CA
91711-3400
US

V. Phone/Fax

Practice location:
  • Phone: 909-568-6816
  • Fax: 909-629-2694
Mailing address:
  • Phone: 909-624-8244
  • Fax: 909-629-2694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP 8223
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number25575
License Number StateCA

VIII. Authorized Official

Name: MS. ANDREA MICHELLE HAYES
Title or Position: PROGRAM DIRECTOR
Credential: M.S. CCC
Phone: 909-641-3776