Provider Demographics
NPI:1477197994
Name:RISA ITANI MS CCC-SLP
Entity Type:Organization
Organization Name:RISA ITANI MS CCC-SLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ITANI
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:352-209-6494
Mailing Address - Street 1:1240 SW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-2906
Mailing Address - Country:US
Mailing Address - Phone:352-209-6494
Mailing Address - Fax:
Practice Address - Street 1:235 SE DAVIS AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1333
Practice Address - Country:US
Practice Address - Phone:541-241-6153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-29
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty