Healthcare Provider Details

I. General information

NPI: 1720339815
Provider Name (Legal Business Name): MAZDA SPEECH-LANGUAGE-DEVELOPMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23734 VALENCIA BLVD. SUITE 304
VALENCIA CA
91355
US

IV. Provider business mailing address

23734 VALENCIA BLVD. SUITE 304
VALENCIA CA
91355
US

V. Phone/Fax

Practice location:
  • Phone: 661-481-0872
  • Fax: 661-481-0723
Mailing address:
  • Phone: 661-481-0872
  • Fax: 661-481-0723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-15203
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number15203
License Number StateCA

VIII. Authorized Official

Name: MS. PERVEEN M. KATRACK
Title or Position: OWNER
Credential: CCC-SLP
Phone: 661-481-0872