Provider Demographics
NPI:1750583274
Name:REAL, JUSTINE MARIE (SLP)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:MARIE
Last Name:REAL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 CLAIRE DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-3534
Mailing Address - Country:US
Mailing Address - Phone:760-521-2902
Mailing Address - Fax:800-803-8147
Practice Address - Street 1:2155 CAMINITO LEONZIO
Practice Address - Street 2:SUITE 20
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-4169
Practice Address - Country:US
Practice Address - Phone:858-733-1954
Practice Address - Fax:800-803-8147
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12322235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist