Provider Demographics
NPI:1538724463
Name:OMIDSALAR, GABRIELA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:
Last Name:OMIDSALAR
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S GOLDEN WEST AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-6211
Mailing Address - Country:US
Mailing Address - Phone:626-807-8465
Mailing Address - Fax:
Practice Address - Street 1:466 FLAGSHIP RD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3635
Practice Address - Country:US
Practice Address - Phone:949-642-8044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27465235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist