Provider Demographics
NPI:1902451362
Name:DOLBERRY, RENEE L (MS, MED, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:L
Last Name:DOLBERRY
Suffix:
Gender:F
Credentials:MS, MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91301
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009-1301
Mailing Address - Country:US
Mailing Address - Phone:310-480-4916
Mailing Address - Fax:
Practice Address - Street 1:555 W COMPTON BLVD STE 106
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-3085
Practice Address - Country:US
Practice Address - Phone:310-637-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP28612235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP28612OtherSTATE OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS
00668004OtherAMERICAN SPEECH & HEARING ASSOCIATION