Provider Demographics
NPI:1437606555
Name:TUSTIN SPEECH THERAPY, INC.
Entity Type:Organization
Organization Name:TUSTIN SPEECH THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KYMRY
Authorized Official - Middle Name:HART
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC, SLP
Authorized Official - Phone:714-838-2853
Mailing Address - Street 1:30 PARMA
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602
Mailing Address - Country:US
Mailing Address - Phone:714-730-4859
Mailing Address - Fax:
Practice Address - Street 1:661 WEST FIRST STREET
Practice Address - Street 2:SUITE E
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780
Practice Address - Country:US
Practice Address - Phone:714-838-2853
Practice Address - Fax:714-838-4533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 10386235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA09116318OtherASHA CCC-SLP
CASP 10386OtherSTATE OF CALIFORNIA - DCA - SPEECH/LANGUAGE PATHOLOGY LICENSE