=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982527834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREENA KUTTOOKARAN PAULOSE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2026
-----------------------------------------------------
Last Update Date | 07/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1305 E VINE ST
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95240-3148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-396-8900
-----------------------------------------------------
Fax | 909-396-8900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 S MILLS AVE APT 66
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95242-4260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-396-8900
-----------------------------------------------------
Fax | 909-396-8900
-----------------------------------------------------
=====================================================
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 | 32105
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------