=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851907281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHATTYKIDDO PEDIATRIC THERAPY A SPEECH PATHOLOGIST CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2020
-----------------------------------------------------
Last Update Date | 09/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 W IMPERIAL HWY STE D
-----------------------------------------------------
City | LA HABRA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90631-6962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-600-0688
-----------------------------------------------------
Fax | 877-595-1830
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2512 COVENTRY CIR
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92833-1281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-600-0688
-----------------------------------------------------
Fax | 877-595-1830
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | NATALIE ROMANCHUKEVICH TIPAKOV
-----------------------------------------------------
Credential | MS/CCC-SLP
-----------------------------------------------------
Telephone | 714-600-0688
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------