MEDICARE: SMILE PEDIATRIC SPEECH THERAPY & DIAGNOSTICS INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst
2	235Z00000X	Speech-Language Pathologist	14510	CA

General Provider Information

NPI Number	:	1265663900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE PEDIATRIC SPEECH THERAPY & DIAGNOSTICS INC.

Provider Business Mailing Address
First Line	:	1639 WATERLOO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90026-2422
Country	:	US
Telephone Number	:	323-747-5055
Fax Number	:	213-483-8537

Provider Business Practice Location Address
First Line	:	3031 BEVERLY BLVD STE B
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-1013
Country	:	US
Telephone Number	:	323-747-5055
Fax Number	:	213-483-8537

Authorized Official
Title or Position	:	DIRECTOR OF CLINICAL SERVICES
Name	:	DANIELLE NICOLE HAJJAR
Credential	:	M.S. CCC-SLP
Telephone Number	:	323-747-5055

Provider Enumeration Date	:	07/29/2009
Last Update Date	:	05/16/2022

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Directions to “SMILE PEDIATRIC SPEECH THERAPY & DIAGNOSTICS INC. ” Practice Location

Language	Start Address	Practice Location

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