Provider Demographics
NPI:1669501011
Name:MARZ, STEPHANIE JILL (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JILL
Last Name:MARZ
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 NW STANNIUM RD.
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701
Mailing Address - Country:US
Mailing Address - Phone:541-382-2585
Mailing Address - Fax:541-382-2585
Practice Address - Street 1:1086 NW STANNIUM RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-2165
Practice Address - Country:US
Practice Address - Phone:541-382-2585
Practice Address - Fax:541-382-2585
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11604235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297166Medicaid