Provider Demographics
NPI:1659650224
Name:BAKHTIYAROVA, GANNA (CFY-SLP)
Entity Type:Individual
Prefix:
First Name:GANNA
Middle Name:
Last Name:BAKHTIYAROVA
Suffix:
Gender:F
Credentials:CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 POND ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-8110
Mailing Address - Country:US
Mailing Address - Phone:608-254-2574
Mailing Address - Fax:608-253-7411
Practice Address - Street 1:300 RACE ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-1822
Practice Address - Country:US
Practice Address - Phone:608-254-2574
Practice Address - Fax:608-253-7411
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3551-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist