=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275996761
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLAUDETTE BANARES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2016
-----------------------------------------------------
Last Update Date | 04/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 E. DEL MAR BLVD. #112
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-564-2700
-----------------------------------------------------
Fax | 626-564-2770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 812 1/2 S GLENOAKS BLVD
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91502-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-206-8267
-----------------------------------------------------
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 | 10486
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 10486
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------