=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467955799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SPEECH STUDIO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2018
-----------------------------------------------------
Last Update Date | 03/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9848 TABOR ST APT 222
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90034-3958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-929-0798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9848 TABOR ST APT 222
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90034-3958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-929-0798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SPEECH THERAPIST
-----------------------------------------------------
Name | SANDRA FUNK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-929-0798
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number | SP24281
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------