Healthcare Provider Details

I. General information

NPI: 1932829934
Provider Name (Legal Business Name): COLLAB PEDIATRIC CLINIC, A SPEECH THERAPY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 01/14/2024
Certification Date: 01/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3252 GABRIELLA ST
WEST COVINA CA
91792-2101
US

IV. Provider business mailing address

3252 GABRIELLA ST
WEST COVINA CA
91792-2101
US

V. Phone/Fax

Practice location:
  • Phone: 626-252-0941
  • Fax:
Mailing address:
  • Phone: 626-252-0941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN WU
Title or Position: CO-OWNER
Credential: CCC-SLP
Phone: 626-739-8775