=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235875238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAY L ESTRADA CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2022
-----------------------------------------------------
Last Update Date | 05/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 W WHITTIER AVE
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92543-5940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-765-1650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25936 GRANT AVE
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92544-5549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-634-2234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 9189
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------