Healthcare Provider Details

I. General information

NPI: 1174271126
Provider Name (Legal Business Name): MARK ALLEN CABRERA CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 YULUPA AVE
SANTA ROSA CA
95405-7018
US

IV. Provider business mailing address

PO BOX 1408
UNION CITY CA
94587-6408
US

V. Phone/Fax

Practice location:
  • Phone: 559-492-8189
  • Fax:
Mailing address:
  • Phone: 559-492-8189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number16566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: