Provider Demographics
NPI:1124171020
Name:ANTICH, NELLY TERESA
Entity type:Individual
Prefix:MRS
First Name:NELLY
Middle Name:TERESA
Last Name:ANTICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NELLY
Other - Middle Name:
Other - Last Name:CANAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:2307 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2650
Mailing Address - Country:US
Mailing Address - Phone:310-376-7735
Mailing Address - Fax:
Practice Address - Street 1:1401 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3010
Practice Address - Country:US
Practice Address - Phone:213-742-5568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5790235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist