Provider Demographics
NPI:1164873402
Name:SHIBATA, KIIYA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIIYA
Middle Name:
Last Name:SHIBATA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 BRANNAN ST UNIT 405
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-1687
Mailing Address - Country:US
Mailing Address - Phone:760-208-5386
Mailing Address - Fax:
Practice Address - Street 1:60 DAGGETT DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-2108
Practice Address - Country:US
Practice Address - Phone:408-434-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP24363235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist