Provider Demographics
NPI:1104471663
Name:LIBAO, TRYSH SACRO (CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRYSH
Middle Name:SACRO
Last Name:LIBAO
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MA PATRICIA YSABEL
Other - Middle Name:SACRO
Other - Last Name:LIBAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:3020 CHILDRENS WAY # MC5010
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3020 CHILDRENS WAY # MC5010
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:909-754-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26229235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist