Provider Demographics
NPI:1578022976
Name:KWON, TATIANA (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TATIANA
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 STATION PARK CIR UNIT 403
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2750
Mailing Address - Country:US
Mailing Address - Phone:408-891-2385
Mailing Address - Fax:
Practice Address - Street 1:2340 IRVING ST STE 108
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-1639
Practice Address - Country:US
Practice Address - Phone:415-218-3506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP23684235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist