Provider Demographics
NPI:1740952852
Name:ASILO, ANNICA MABUNGA
Entity type:Individual
Prefix:MS
First Name:ANNICA MABUNGA
Middle Name:
Last Name:ASILO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 RAY ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-6621
Mailing Address - Country:US
Mailing Address - Phone:925-399-5796
Mailing Address - Fax:925-249-5121
Practice Address - Street 1:311 RAY ST
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-6621
Practice Address - Country:US
Practice Address - Phone:925-399-5796
Practice Address - Fax:925-249-5121
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA208610724OtherSPEECH THERAPY