Provider Demographics
NPI:1750708574
Name:THRIVE AND SHINE: SPEECH-LANGUAGE PATHOLOGY
Entity type:Organization
Organization Name:THRIVE AND SHINE: SPEECH-LANGUAGE PATHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:NEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:REZAPOOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-866-9958
Mailing Address - Street 1:8230 BEVERLY BLVD
Mailing Address - Street 2:#30
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4528
Mailing Address - Country:US
Mailing Address - Phone:310-866-9958
Mailing Address - Fax:
Practice Address - Street 1:8230 BEVERLY BLVD
Practice Address - Street 2:#30
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4528
Practice Address - Country:US
Practice Address - Phone:310-866-9958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20444251E00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHD656AMedicare Oscar/Certification