Provider Demographics
NPI:1043385727
Name:ISAACSON, TED MATTHEW (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:MATTHEW
Last Name:ISAACSON
Suffix:
Gender:M
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N Z ST
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436
Mailing Address - Country:US
Mailing Address - Phone:805-736-0363
Mailing Address - Fax:805-736-0363
Practice Address - Street 1:191 WEST BURTON MESA BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436
Practice Address - Country:US
Practice Address - Phone:805-733-4542
Practice Address - Fax:805-733-4392
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP12824235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0663623OtherTRIWEST
CAGSP000390Medicaid
CAGSP000390Medicaid