Provider Demographics
NPI:1982574687
Name:SUGIMOTO, AUDREY AKIKO
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:AKIKO
Last Name:SUGIMOTO
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 SAN JACINTO ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2395
Mailing Address - Country:US
Mailing Address - Phone:805-657-1756
Mailing Address - Fax:
Practice Address - Street 1:4628 S 144TH ST
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98168-4134
Practice Address - Country:US
Practice Address - Phone:206-901-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-07
Last Update Date:2025-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38460235Z00000X
WASLP.LL.70030853235Z00000X
MASLP101710235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist