Healthcare Provider Details

I. General information

NPI: 1285435560
Provider Name (Legal Business Name): JUAN PABLO HERRERA OBALDO SLPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 W 11TH ST STE 119
TRACY CA
95376-3860
US

IV. Provider business mailing address

632 W 11TH ST STE 119
TRACY CA
95376-3860
US

V. Phone/Fax

Practice location:
  • Phone: 209-237-2484
  • Fax: 209-237-2485
Mailing address:
  • Phone: 209-237-2484
  • Fax: 209-237-2485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number5677
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: