Healthcare Provider Details

I. General information

NPI: 1639396286
Provider Name (Legal Business Name): SPEECH LANGUAGE PATHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12791 NEWPORT AVE SUITE 101
TUSTIN CA
92780-2751
US

IV. Provider business mailing address

12791 NEWPORT AVE SUITE 101
TUSTIN CA
92780-2751
US

V. Phone/Fax

Practice location:
  • Phone: 714-544-1860
  • Fax: 714-730-5372
Mailing address:
  • Phone: 714-544-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberSP 3165
License Number StateCA

VIII. Authorized Official

Name: CHRISTINE SWITZER
Title or Position: OWNER, SPEECH PATHOLOGIST
Credential: MA
Phone: 714-544-1860