=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659003804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILLIPS SPEECH THERAPY CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2022
-----------------------------------------------------
Last Update Date | 06/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 439 N EL CAMINO REAL STE D
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92672-4700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-747-4298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24551 DEL PRADO UNIT 4154
-----------------------------------------------------
City | DANA POINT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92629-6302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-747-4298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEAD SPEECH THERAPIST
-----------------------------------------------------
Name | RILEY PHILLIPS
-----------------------------------------------------
Credential | MS, CCC-SLP
-----------------------------------------------------
Telephone | 909-747-4298
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------