Provider Demographics
NPI:1386001972
Name:LIFESPAN THERAPEUTIC SERVICES SPEECH PATHOLOGIST
Entity Type:Organization
Organization Name:LIFESPAN THERAPEUTIC SERVICES SPEECH PATHOLOGIST
Other - Org Name:LIFESPAN THERAPEUTIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA SLP
Authorized Official - Phone:424-201-1631
Mailing Address - Street 1:23639 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5930
Mailing Address - Country:US
Mailing Address - Phone:424-201-1631
Mailing Address - Fax:310-265-4775
Practice Address - Street 1:23639 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5930
Practice Address - Country:US
Practice Address - Phone:424-201-1631
Practice Address - Fax:310-265-4775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4849235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty