Provider Demographics
NPI:1215993704
Name:PROVIDENCE SPEECH & HEARING CENTER
Entity type:Organization
Organization Name:PROVIDENCE SPEECH & HEARING CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ELQURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-509-3000
Mailing Address - Street 1:1201 W LA VETA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4203
Mailing Address - Country:US
Mailing Address - Phone:714-509-3000
Mailing Address - Fax:714-744-3841
Practice Address - Street 1:1301 W PROVIDENCE AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3808
Practice Address - Country:US
Practice Address - Phone:714-639-4990
Practice Address - Fax:714-744-3841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 252Y00000X
CA231H00000X, 235Z00000X, 237700000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01182ZOtherBLUE SHIELD SPEECH
CAGAU000910Medicaid
CAZZZ05424ZOtherBLUE SHIELD OT
CAGSP000640Medicaid
CAZZZ02320ZOtherBLUE SHIELD AUDIO
CAZZZ43525ZOtherBLUE SHIELD HEARING AID
CAGSP000640Medicaid
CA=========OtherOTHER INSURANCES