MEDICARE: LITTLE ROSE SPEECH THERAPY, 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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1922605898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE ROSE SPEECH THERAPY, INC.

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	:	619-800-2517
Fax Number	:

Provider Business Practice Location Address
First Line	:	11990 STONEY PEAK DR APT 1106
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-6481
Country	:	US
Telephone Number	:	619-800-2517
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DIANA RIDOLOSO
Credential	:	M.S., CCC-SLP
Telephone Number	:	209-406-7619

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	10/05/2020

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Directions to “LITTLE ROSE SPEECH THERAPY, INC. ” Practice Location

Language	Start Address	Practice Location

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