Provider Demographics
NPI:1043631336
Name:BELLEZZA, GWENDOLYN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:
Last Name:BELLEZZA
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 1:25 POPPYFIELD LN
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-8725
Mailing Address - Country:US
Mailing Address - Phone:760-221-7202
Mailing Address - Fax:
Practice Address - Street 1:1120 VIA CALLEJON
Practice Address - Street 2:SUITE B
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6213
Practice Address - Country:US
Practice Address - Phone:949-498-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP21508235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist