Provider Demographics
NPI:1619256948
Name:MIZIKAR, JEANINE M (MACCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:JEANINE
Middle Name:M
Last Name:MIZIKAR
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 ANTHONY WAYNE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BADEN
Mailing Address - State:PA
Mailing Address - Zip Code:15005-2105
Mailing Address - Country:US
Mailing Address - Phone:724-875-0901
Mailing Address - Fax:
Practice Address - Street 1:310 WAYNE STREET
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-2252
Practice Address - Country:US
Practice Address - Phone:724-774-2677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010486235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist