=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295914448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMARA ELKINS KOHNKE M.A., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2007
-----------------------------------------------------
Last Update Date | 10/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4650 W SUNSET BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027-6062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-316-4035
-----------------------------------------------------
Fax | 323-361-1283
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4650 W SUNSET BLVD P.O. BOX 27980, MAILSTOP #36
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027-6062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-316-4035
-----------------------------------------------------
Fax | 323-361-1283
-----------------------------------------------------
=====================================================
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 | 16392
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------