Provider Demographics
NPI:1629120068
Name:CENTER FOR SPEECH, LANGUAGE AND OCCUPATIONAL THERAPY A PROF CORP
Entity Type:Organization
Organization Name:CENTER FOR SPEECH, LANGUAGE AND OCCUPATIONAL THERAPY A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:CCCSLP
Authorized Official - Phone:650-322-5230
Mailing Address - Street 1:39420 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-2200
Mailing Address - Country:US
Mailing Address - Phone:510-794-5155
Mailing Address - Fax:510-794-1912
Practice Address - Street 1:39420 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2200
Practice Address - Country:US
Practice Address - Phone:510-794-5155
Practice Address - Fax:510-794-1912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55-6526Medicare UPIN
CA55-6519Medicare UPIN