Provider Demographics
NPI:1447704341
Name:OBUSAN, STEPHANIE BOAYES
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BOAYES
Last Name:OBUSAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 257TH ST APT 9
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-2761
Mailing Address - Country:US
Mailing Address - Phone:310-529-0194
Mailing Address - Fax:
Practice Address - Street 1:3521 LOMITA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5040
Practice Address - Country:US
Practice Address - Phone:310-856-8528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASPA 34182355S0801X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant