Provider Demographics
NPI:1831653385
Name:BALTHAZAR, PATRICIA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BALTHAZAR
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 W OLIVE AVE # A
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5154
Mailing Address - Country:US
Mailing Address - Phone:517-927-1598
Mailing Address - Fax:
Practice Address - Street 1:22365 BARTON RD STE 104
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5037
Practice Address - Country:US
Practice Address - Phone:909-824-2899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty