Basic Information
Provider Information
NPI: 1003150087
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SERRANO
FirstName: MARIBEL
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.S., CCC-SLP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: HOLDER
OtherFirstName: MARIBEL
OtherMiddleName: SERRANO
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: MS, CCC-SLP
OtherLastNameType: 2
Mailing Information
Address1: 1023 DIVISADERO ST
Address2:  
City: SAN FRANCISCO
State: CA
PostalCode: 941154408
CountryCode: US
TelephoneNumber: 5202237500
FaxNumber:  
Practice Location
Address1: 88 CRESTLINE DR
Address2: #9
City: SAN FRANCISCO
State: CA
PostalCode: 941311443
CountryCode: US
TelephoneNumber: 5202237500
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/15/2012
LastUpdateDate: 04/17/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000X18977CAY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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