Healthcare Provider Details

I. General information

NPI: 1689494684
Provider Name (Legal Business Name): JOSEPH ROBERT MCGINNIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

1510 SAN LORENZO AVE
BERKELEY CA
94707-1821
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-1000
  • Fax:
Mailing address:
  • Phone: 510-295-7686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number20040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: