Provider Demographics
NPI:1093119943
Name:SHAKED, LEEYA
Entity Type:Individual
Prefix:
First Name:LEEYA
Middle Name:
Last Name:SHAKED
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 1:627 SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3443
Mailing Address - Country:US
Mailing Address - Phone:818-933-1413
Mailing Address - Fax:
Practice Address - Street 1:2990 S SEPULVEDA BLVD
Practice Address - Street 2:#308
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-0002
Practice Address - Country:US
Practice Address - Phone:310-444-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21076235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist