Provider Demographics
NPI:1134771512
Name:ST MARTIN, THAIS DINESE (MASTERS OF SCIENCE)
Entity type:Individual
Prefix:MRS
First Name:THAIS
Middle Name:DINESE
Last Name:ST MARTIN
Suffix:
Gender:F
Credentials:MASTERS OF SCIENCE
Other - Prefix:MISS
Other - First Name:THAIS
Other - Middle Name:DINESE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASTERS OF SCIENCE
Mailing Address - Street 1:10180 OBRIEN PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2922
Mailing Address - Country:US
Mailing Address - Phone:714-293-0033
Mailing Address - Fax:
Practice Address - Street 1:12335 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040
Practice Address - Country:US
Practice Address - Phone:619-390-2391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12260235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist