Healthcare Provider Details

I. General information

NPI: 1063185957
Provider Name (Legal Business Name): MYRA MAE SIA HAYA CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2185 W GRANT LINE RD
TRACY CA
95377-7309
US

IV. Provider business mailing address

3000 GARDEN CT
TRACY CA
95377-9237
US

V. Phone/Fax

Practice location:
  • Phone: 209-839-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number40540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: