Provider Demographics
NPI:1407418189
Name:MCINNIS, COLIN MATTHEW (SLPA)
Entity Type:Individual
Prefix:MR
First Name:COLIN
Middle Name:MATTHEW
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 CHILPANCINGO PKWY APT 283
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-1351
Mailing Address - Country:US
Mailing Address - Phone:209-479-4184
Mailing Address - Fax:
Practice Address - Street 1:4400 KELLER AVE STE 200
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-4229
Practice Address - Country:US
Practice Address - Phone:510-639-2929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55772355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant