Provider Demographics
NPI:1093859084
Name:COMMUNITY SPEECH CENTER OF UPLAND
Entity Type:Organization
Organization Name:COMMUNITY SPEECH CENTER OF UPLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:MADKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC SLP
Authorized Official - Phone:909-908-1771
Mailing Address - Street 1:900 E HARRISON AVE APT C23
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2043
Mailing Address - Country:US
Mailing Address - Phone:909-908-1771
Mailing Address - Fax:909-981-2039
Practice Address - Street 1:900 E HARRISON AVE APT C23
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2043
Practice Address - Country:US
Practice Address - Phone:909-541-7654
Practice Address - Fax:909-626-7977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 1902235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ57586YOtherBLUE SHIELD OF CALIFORNIA