Healthcare Provider Details

I. General information

NPI: 1033738224
Provider Name (Legal Business Name): RICHARD MARC LIWANAG MS, CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5767 MISSION ST
SAN FRANCISCO CA
94112-4208
US

IV. Provider business mailing address

2145 32ND AVE
SAN FRANCISCO CA
94116-1624
US

V. Phone/Fax

Practice location:
  • Phone: 415-584-3294
  • Fax:
Mailing address:
  • Phone: 559-246-1863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number24296
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: