Provider Demographics
NPI:1558124354
Name:PENALONZO, MIKAELA BRIANA
Entity Type:Individual
Prefix:MRS
First Name:MIKAELA BRIANA
Middle Name:
Last Name:PENALONZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKAELA
Other - Middle Name:
Other - Last Name:LICUDINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26033 CAPE DR UNIT 376
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-0931
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3722 KATELLA AVE STE C
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3102
Practice Address - Country:US
Practice Address - Phone:562-270-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82382355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant