Healthcare Provider Details

I. General information

NPI: 1205092053
Provider Name (Legal Business Name): SAN DIEGO COUNTY SPEECH PATHOLOGY SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CAMINO DEL RIO S 101
SAN DIEGO CA
92108-3530
US

IV. Provider business mailing address

411 CAMINO DEL RIO S 101
SAN DIEGO CA
92108-3530
US

V. Phone/Fax

Practice location:
  • Phone: 619-574-8181
  • Fax: 619-574-0802
Mailing address:
  • Phone: 619-574-8181
  • Fax: 619-574-0802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberSP1579
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP1579
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. JUDY L LEWIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 619-574-8181