Provider Demographics
NPI:1083336838
Name:PRIEST, MISA
Entity Type:Individual
Prefix:
First Name:MISA
Middle Name:
Last Name:PRIEST
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 1:3265 S SEPULVEDA BLVD APT 305
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-5219
Mailing Address - Country:US
Mailing Address - Phone:408-318-7459
Mailing Address - Fax:
Practice Address - Street 1:3265 S SEPULVEDA BLVD APT 305
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-5219
Practice Address - Country:US
Practice Address - Phone:408-318-7459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20816235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist