Provider Demographics
NPI:1619170537
Name:OSORIO, IVETTE
Entity Type:Individual
Prefix:
First Name:IVETTE
Middle Name:
Last Name:OSORIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13080 PACIFIC PROMENADE
Mailing Address - Street 2:#213
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094
Mailing Address - Country:US
Mailing Address - Phone:310-210-3190
Mailing Address - Fax:
Practice Address - Street 1:13080 PACIFIC PROMENADE
Practice Address - Street 2:#213
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094
Practice Address - Country:US
Practice Address - Phone:310-210-3190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP16086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist