Provider Demographics
NPI:1285221101
Name:CONTRERAS-PROVOST, DESIREE (SLP)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:CONTRERAS-PROVOST
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:
Other - Last Name:PROVOST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SLP
Mailing Address - Street 1:8243 APPLE COVE CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95828-5711
Mailing Address - Country:US
Mailing Address - Phone:916-897-0549
Mailing Address - Fax:
Practice Address - Street 1:2910 MCCLURE ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3505
Practice Address - Country:US
Practice Address - Phone:510-836-3677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-26
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32962235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty