Provider Demographics
NPI:1124852140
Name:MINDFUL SPEECH PATH
Entity type:Organization
Organization Name:MINDFUL SPEECH PATH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DELISSER
Authorized Official - Suffix:
Authorized Official - Credentials:MHS-CCC-SLP
Authorized Official - Phone:347-720-2773
Mailing Address - Street 1:6228 FULTON AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-2553
Mailing Address - Country:US
Mailing Address - Phone:347-720-2773
Mailing Address - Fax:
Practice Address - Street 1:6228 FULTON AVE APT 204
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-2553
Practice Address - Country:US
Practice Address - Phone:347-720-2773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health