Provider Demographics
NPI:1548729122
Name:FULL POTENTIAL SPEECH THERAPY CENTER, INC
Entity type:Organization
Organization Name:FULL POTENTIAL SPEECH THERAPY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GISONDA
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:949-606-6487
Mailing Address - Street 1:44881 TROTSDALE DR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-5874
Mailing Address - Country:US
Mailing Address - Phone:951-331-2154
Mailing Address - Fax:
Practice Address - Street 1:27393 YNEZ RD STE 153
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4605
Practice Address - Country:US
Practice Address - Phone:951-331-2154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-13
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1578049094OtherNPI TYPE 1