Provider Demographics
NPI:1922654482
Name:BUMACOD, GRACE (SPEECH PATHOLOGIST)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:BUMACOD
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 E VERDUGO AVE APT L
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-2339
Mailing Address - Country:US
Mailing Address - Phone:818-452-8124
Mailing Address - Fax:
Practice Address - Street 1:245 W SIERRA MADRE BLVD
Practice Address - Street 2:
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024-2355
Practice Address - Country:US
Practice Address - Phone:626-822-5992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19239235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist