Provider Demographics
NPI:1073059572
Name:CHUDNOVSKAYA, LARISA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:CHUDNOVSKAYA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19750 S VERMONT AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-1119
Mailing Address - Country:US
Mailing Address - Phone:424-233-3700
Mailing Address - Fax:
Practice Address - Street 1:10800 FARRAGUT DR
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4107
Practice Address - Country:US
Practice Address - Phone:424-341-0151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2021-03-25
Deactivation Date:2021-03-03
Deactivation Code:
Reactivation Date:2021-03-23
Provider Licenses
StateLicense IDTaxonomies
CARPE 11102390200000X
CA26048235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program