Provider Demographics
NPI:1578703476
Name:PRINCE, PRUDENCE JAYE (SLPA)
Entity Type:Individual
Prefix:MRS
First Name:PRUDENCE
Middle Name:JAYE
Last Name:PRINCE
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 ACACIA AVE
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-2527
Mailing Address - Country:US
Mailing Address - Phone:619-316-9541
Mailing Address - Fax:
Practice Address - Street 1:9606 TIERRA GRANDE ST STE 107
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-6501
Practice Address - Country:US
Practice Address - Phone:858-695-9415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-05
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9772355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant