Provider Demographics
NPI:1801091590
Name:KISSEL, ROBERT JAY (MACCCSLP)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JAY
Last Name:KISSEL
Suffix:
Gender:M
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 W STEVENS AVE APT 147
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-5063
Mailing Address - Country:US
Mailing Address - Phone:714-549-5045
Mailing Address - Fax:
Practice Address - Street 1:16 TECHNOLOGY DR STE 116
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2326
Practice Address - Country:US
Practice Address - Phone:949-462-9802
Practice Address - Fax:949-462-9824
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3619235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist