Provider Demographics
NPI:1316016181
Name:FAZELY, MONDRA ROSE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MONDRA
Middle Name:ROSE
Last Name:FAZELY
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 1:637 CARRIAGE WAY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4832
Mailing Address - Country:US
Mailing Address - Phone:225-769-7479
Mailing Address - Fax:225-923-1326
Practice Address - Street 1:8676 GOODWOOD BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7914
Practice Address - Country:US
Practice Address - Phone:225-923-1140
Practice Address - Fax:225-923-1326
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2002235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist