Provider Demographics
NPI:1043830250
Name:GOLBOLAKH, ATIN TINA
Entity Type:Individual
Prefix:
First Name:ATIN
Middle Name:TINA
Last Name:GOLBOLAKH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24930 AVENUE STANFORD
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1272
Mailing Address - Country:US
Mailing Address - Phone:661-294-5300
Mailing Address - Fax:
Practice Address - Street 1:24930 AVENUE STANFORD
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91355-1272
Practice Address - Country:US
Practice Address - Phone:661-294-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18985235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist