Provider Demographics
NPI:1932829934
Name:COLLAB PEDIATRIC CLINIC, A SPEECH THERAPY CORPORATION
Entity type:Organization
Organization Name:COLLAB PEDIATRIC CLINIC, A SPEECH THERAPY CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:626-739-8775
Mailing Address - Street 1:3252 GABRIELLA ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-2101
Mailing Address - Country:US
Mailing Address - Phone:626-252-0941
Mailing Address - Fax:
Practice Address - Street 1:3252 GABRIELLA ST
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-2101
Practice Address - Country:US
Practice Address - Phone:626-252-0941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-30
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and SpeechGroup - Single Specialty