Basic Information
Provider Information
NPI: 1063750628
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TEETER
FirstName: ALICIA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: CCC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4010 MOORPARK AVE
Address2: 117
City: SAN JOSE
State: CA
PostalCode: 951174101
CountryCode: US
TelephoneNumber: 4082490770
FaxNumber: 4088347767
Practice Location
Address1: 4010 MOORPARK AVE
Address2: 117
City: SAN JOSE
State: CA
PostalCode: 951174101
CountryCode: US
TelephoneNumber: 4082490770
FaxNumber: 4088347767
Other Information
ProviderEnumerationDate: 01/16/2013
LastUpdateDate: 01/16/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000X17524CAY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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