MEDICARE: MS. DIANA RIDOLOSO M.S. CCC-SLP

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	235Z00000X	Speech-Language Pathologist	25271	CA

General Provider Information

NPI Number	:	1710478052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANA RIDOLOSO M.S. CCC-SLP

Provider Business Mailing Address
First Line	:	11990 STONEY PEAK DR APT 1106
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-6481
Country	:	US
Telephone Number	:	209-406-7619
Fax Number	:

Provider Business Practice Location Address
First Line	:	11990 STONEY PEAK DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-5402
Country	:	US
Telephone Number	:	619-800-2517
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2018
Last Update Date	:	09/16/2020

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Directions to “ MS. DIANA RIDOLOSO M.S. CCC-SLP” Practice Location

Language	Start Address	Practice Location

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