Provider Demographics
NPI:1396081188
Name:MLADY-FLETCHER, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MLADY-FLETCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 PROSPECT DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-3424
Mailing Address - Country:US
Mailing Address - Phone:818-523-4478
Mailing Address - Fax:
Practice Address - Street 1:19100 VENTURA BLVD
Practice Address - Street 2:SUITE Q
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3239
Practice Address - Country:US
Practice Address - Phone:818-708-7704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-24
Last Update Date:2012-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist