Provider Demographics
NPI:1396905261
Name:TYAGI, MUKESH (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MUKESH
Middle Name:
Last Name:TYAGI
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 W LA VETA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4302
Mailing Address - Country:US
Mailing Address - Phone:714-633-3568
Mailing Address - Fax:
Practice Address - Street 1:920 W LA VETA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4302
Practice Address - Country:US
Practice Address - Phone:714-633-3568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 15133235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist