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General NPI Number Information
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NPI Number | 1720220817
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Entity Type | Organization
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Legal Business Name | DIRECT THERAPY, S&P
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Dates
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Enumeration Date | 04/03/2009
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Last Update Date | 09/14/2015
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Provider Practice Location Address
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Address Line | 1900 ROYALTY DRIVE, SUITE 210
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City | POMONA
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State | CA
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Zip | 91767
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Country | US
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Telephone | 909-568-6816
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Fax | 909-629-2694
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Provider Business Mailing Address
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Address Line | 265 W. SONORA PLACE
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City | CLAREMONT
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State | CA
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Zip | 91711-3400
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Country | US
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Telephone | 909-624-8244
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Fax | 909-629-2694
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MS. ANDREA MICHELLE HAYES
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Credential | M.S. CCC
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Telephone | 909-641-3776
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 25575
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SP 8223
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License Number State | CA
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