Provider Demographics
NPI:1780702001
Name:MID PENINSULA SPEECH AND LANGUAGE CLINIC
Entity type:Organization
Organization Name:MID PENINSULA SPEECH AND LANGUAGE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:DAGENAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC
Authorized Official - Phone:650-380-4929
Mailing Address - Street 1:2625 MIDDLEFIELD RD. #558
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-2516
Mailing Address - Country:US
Mailing Address - Phone:650-321-8111
Mailing Address - Fax:650-321-8122
Practice Address - Street 1:102 FERNE AVE.
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-4644
Practice Address - Country:US
Practice Address - Phone:650-380-4929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2651235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty