Provider Demographics
NPI:1336512607
Name:PANSEWICZ, JULIA
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:PANSEWICZ
Suffix:
Gender:F
Credentials:
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 881
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:WY
Mailing Address - Zip Code:83014-0881
Mailing Address - Country:US
Mailing Address - Phone:802-233-3050
Mailing Address - Fax:
Practice Address - Street 1:165 FRONT ST
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5445
Practice Address - Country:US
Practice Address - Phone:208-716-2351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-08
Last Update Date:2015-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-2786235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist