Provider Demographics
NPI:1548659220
Name:VENUGOPAL, SELVARANI (SPEECH THERAPIST)
Entity type:Individual
Prefix:
First Name:SELVARANI
Middle Name:
Last Name:VENUGOPAL
Suffix:
Gender:F
Credentials:SPEECH THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5446 AMETHYST LN
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-8731
Mailing Address - Country:US
Mailing Address - Phone:909-334-0411
Mailing Address - Fax:
Practice Address - Street 1:14318 OHIO ST
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-2553
Practice Address - Country:US
Practice Address - Phone:626-960-1971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-17
Last Update Date:2015-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP15886235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist