Provider Demographics
NPI:1619292539
Name:INNOVATIVE THERAPY SERVICES-PEDIATRIC SPEECH & LANGUAGE THERAPY SERVIC
Entity Type:Organization
Organization Name:INNOVATIVE THERAPY SERVICES-PEDIATRIC SPEECH & LANGUAGE THERAPY SERVIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:UDUAK
Authorized Official - Middle Name:
Authorized Official - Last Name:OSOM
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:408-241-2229
Mailing Address - Street 1:1090 HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-5402
Mailing Address - Country:US
Mailing Address - Phone:408-241-2229
Mailing Address - Fax:408-241-3156
Practice Address - Street 1:1090 HOMESTEAD RD
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-5402
Practice Address - Country:US
Practice Address - Phone:408-241-2229
Practice Address - Fax:408-241-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-03
Last Update Date:2010-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP10585235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty