Provider Demographics
NPI:1598327520
Name:JATCZAK, LAURIE (CF-SLP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:JATCZAK
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9309 MONTEMAR DR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-3419
Mailing Address - Country:US
Mailing Address - Phone:360-969-6305
Mailing Address - Fax:
Practice Address - Street 1:17100 E SHEA BLVD STE 600
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-6663
Practice Address - Country:US
Practice Address - Phone:480-837-4565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-29
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP11868235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZTSLP11868OtherARIZONA DEPARTMENT OF HEALTH SERVICES