Healthcare Provider Details

I. General information

NPI: 1942877113
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA SPEECH LANGUAGE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8062 CALLE CARABE CT
RANCHO CUCAMONGA CA
91730-1903
US

IV. Provider business mailing address

1215 PIEDMONT DR
UPLAND CA
91784-1053
US

V. Phone/Fax

Practice location:
  • Phone: 909-802-0916
  • Fax:
Mailing address:
  • Phone: 909-802-0916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JASMINE T MCCONNELL
Title or Position: OWNER
Credential: MA, CCC-SLP
Phone: 909-802-0916