{
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"FirstLineMailingAddress": "1381 MILLWOOD DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "RIVERSIDE",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "92506-5306",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "951-750-9494",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "6670 ALESSANDRO BLVD STE G",
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"PracticeLocationAddressCityName": "RIVERSIDE",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "92506-5334",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "951-588-5361",
"PracticeLocationAddressFaxNumber": "951-900-3777",
"EnumerationDate": "07/20/2018",
"LastUpdateDate": "07/30/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GAMBINO",
"AuthorizedOfficialFirstName": "MEGAN",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CEO",
"AuthorizedOfficialNamePrefix": "MRS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MS, CCC-SLP",
"AuthorizedOfficialTelephoneNumber": "951-750-9494",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "235Z00000X",
"TaxonomyName": "Speech-Language Pathologist",
"LicenseNumber": "23910",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}