=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588934194
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DYANELLE SANFORD CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2012
-----------------------------------------------------
Last Update Date | 01/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12411 SLAUSON AVE STE H
-----------------------------------------------------
City | WHITTIER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90606-2835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-693-5449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2115 GRANT AVE APT 1
-----------------------------------------------------
City | REDONDO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90278-3639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-372-8097
-----------------------------------------------------
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 | SP18080
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------