Provider Demographics
NPI:1396372769
Name:CHAGOLLA, KIMBERLY MICHELLE (SLPA, BA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:CHAGOLLA
Suffix:
Gender:F
Credentials:SLPA, BA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:CHAGOLLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLPA, BA
Mailing Address - Street 1:26623 PLACENTIA AVE
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-7302
Mailing Address - Country:US
Mailing Address - Phone:323-861-9824
Mailing Address - Fax:
Practice Address - Street 1:26623 PLACENTIA AVE
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-7302
Practice Address - Country:US
Practice Address - Phone:323-861-9824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51792355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty