Provider Demographics
NPI:1639724776
Name:OMWANGHE, KEISHA (MCD,CCC-SLP)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:OMWANGHE
Suffix:
Gender:F
Credentials:MCD,CCC-SLP
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14369 PARK AVE STE 201A
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2300
Mailing Address - Country:US
Mailing Address - Phone:760-278-1484
Mailing Address - Fax:855-719-2558
Practice Address - Street 1:14369 PARK AVE STE 201A
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2300
Practice Address - Country:US
Practice Address - Phone:760-278-1484
Practice Address - Fax:855-719-8152
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38218235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist