=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346704053
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BIANCA SARAH ROSENTHAL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2019
-----------------------------------------------------
Last Update Date | 01/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 N F ST
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92410-3017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-381-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 VOLAR ST
-----------------------------------------------------
City | RANCHO MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694-1860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-910-1937
-----------------------------------------------------
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 | 17934
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------