Provider Demographics
NPI:1316300973
Name:SCANLON, KERSTEN (MA,CCC-SLP)
Entity type:Individual
Prefix:
First Name:KERSTEN
Middle Name:
Last Name:SCANLON
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3906
Mailing Address - Country:US
Mailing Address - Phone:310-480-9139
Mailing Address - Fax:
Practice Address - Street 1:1336 W 13TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3906
Practice Address - Country:US
Practice Address - Phone:310-480-9139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22940235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist