=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891433884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOCAL THERAPY NETWORK, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2022
-----------------------------------------------------
Last Update Date | 05/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2108 N ST STE N
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95816-5712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-338-9891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2108 N ST STE N
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95816-5712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-338-9891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHEA FITZGERALD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-338-9891
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------