Provider Demographics
NPI:1720220817
Name:DIRECT THERAPY, S&P
Entity Type:Organization
Organization Name:DIRECT THERAPY, S&P
Other - Org Name:DIRECT THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC
Authorized Official - Phone:909-641-3776
Mailing Address - Street 1:265 W. SONORA PLACE
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-3400
Mailing Address - Country:US
Mailing Address - Phone:909-624-8244
Mailing Address - Fax:909-629-2694
Practice Address - Street 1:1900 ROYALTY DRIVE, SUITE 210
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767
Practice Address - Country:US
Practice Address - Phone:909-568-6816
Practice Address - Fax:909-629-2694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 8223235Z00000X
CA25575335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty