Provider Demographics
NPI:1619453735
Name:DE FALKENBERG, TERA LYNN (MA, SLP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:TERA
Middle Name:LYNN
Last Name:DE FALKENBERG
Suffix:
Gender:F
Credentials:MA, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3578 MUSTANG DR
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-9198
Mailing Address - Country:US
Mailing Address - Phone:909-231-9011
Mailing Address - Fax:
Practice Address - Street 1:3578 MUSTANG DR
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-9198
Practice Address - Country:US
Practice Address - Phone:909-231-9011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15559235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist