Healthcare Provider Details

I. General information

NPI: 1003113408
Provider Name (Legal Business Name): PATHWAYS 2 SPEECH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2011
Last Update Date: 02/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 FRANKLIN LN
VISTA CA
92084-5153
US

IV. Provider business mailing address

719 FRANKLIN LN
VISTA CA
92084-5153
US

V. Phone/Fax

Practice location:
  • Phone: 760-518-8563
  • Fax: 760-480-7366
Mailing address:
  • Phone: 760-518-8563
  • Fax: 760-480-7366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberCERT. AVT 1031201020
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP9784
License Number StateCA

VIII. Authorized Official

Name: MRS. MARY ELIZABETH CLEMONS
Title or Position: LSLS CERT. AVT, CCC-SLP
Credential: M.A.
Phone: 760-518-8563