Provider Demographics
NPI:1346496742
Name:FAZ, SHERRY L (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:L
Last Name:FAZ
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 OAKRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7077
Mailing Address - Country:US
Mailing Address - Phone:270-843-3296
Mailing Address - Fax:
Practice Address - Street 1:212 OAKRIDGE WAY
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7077
Practice Address - Country:US
Practice Address - Phone:270-843-3296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3082235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3082Medicare UPIN