Provider Demographics
NPI:1770983322
Name:TENGAN, MINDI
Entity type:Individual
Prefix:
First Name:MINDI
Middle Name:
Last Name:TENGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MINDI
Other - Middle Name:
Other - Last Name:DEGUCHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 768787
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8210
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:5312 BOLSA AVE STE 105
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-1060
Practice Address - Country:US
Practice Address - Phone:855-295-3276
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP23152235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASPA 1714OtherSLPA