Provider Demographics
NPI:1639319247
Name:GRZESIK, KATHLEEN ELIZABETH (MACFSLP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:GRZESIK
Suffix:
Gender:F
Credentials:MACFSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 S TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1567
Mailing Address - Country:US
Mailing Address - Phone:314-977-0192
Mailing Address - Fax:314-977-0023
Practice Address - Street 1:825 S TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1567
Practice Address - Country:US
Practice Address - Phone:314-977-0192
Practice Address - Fax:314-977-0023
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008020479235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO468375506Medicaid