MEDICARE: DOUGLAS SPEECH ASSOCIATES

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	252Y00000X	Early Intervention Provider Agency	SP#11478	CA
2	235Z00000X	Speech-Language Pathologist	SP#11478	CA

General Provider Information

NPI Number	:	1952712754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLAS SPEECH ASSOCIATES

Provider Business Mailing Address
First Line	:	1680 VINE ST
Second Line	:	SUITE 300
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-8804
Country	:	US
Telephone Number	:	323-960-0176
Fax Number	:	323-960-0714

Provider Business Practice Location Address
First Line	:	1680 VINE ST
Second Line	:	SUITE 300
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-8804
Country	:	US
Telephone Number	:	323-960-0176
Fax Number	:	323-960-0714

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	JENNIFER GARRETT DOUGLAS
Credential	:	CCC-SLP
Telephone Number	:	323-960-0176

Provider Enumeration Date	:	05/14/2014
Last Update Date	:	05/14/2014

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Directions to “DOUGLAS SPEECH ASSOCIATES ” Practice Location

Language	Start Address	Practice Location

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