Provider Demographics
NPI:1497915805
Name:FAKE, LINDA D (MA)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:D
Last Name:FAKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4009 MALCOLM AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-5460
Mailing Address - Country:US
Mailing Address - Phone:510-752-7608
Mailing Address - Fax:
Practice Address - Street 1:235 W MACARTHUR BLVD
Practice Address - Street 2:SUITE 520
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5641
Practice Address - Country:US
Practice Address - Phone:510-752-7608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 5365235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist