Provider Demographics
NPI:1104299700
Name:LO, WELBY JOSEPH (CCC-SLP)
Entity type:Individual
Prefix:
First Name:WELBY
Middle Name:JOSEPH
Last Name:LO
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 MONO WAY
Mailing Address - Street 2:SPORTS MEDICINE AND REHABILITATION
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370
Mailing Address - Country:US
Mailing Address - Phone:209-536-6920
Mailing Address - Fax:
Practice Address - Street 1:900 MONO WAY
Practice Address - Street 2:SPORTS MEDICINE AND REHABILITATION
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370
Practice Address - Country:US
Practice Address - Phone:209-536-6920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10300235Z00000X
CA25209235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist