Provider Demographics
NPI:1700384971
Name:BLASZCZYK, RANDY (CCC-SLP/L)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:BLASZCZYK
Suffix:
Gender:M
Credentials:CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 S AUSTIN BLVD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2616
Mailing Address - Country:US
Mailing Address - Phone:708-780-2800
Mailing Address - Fax:
Practice Address - Street 1:2423 S AUSTIN BLVD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2616
Practice Address - Country:US
Practice Address - Phone:708-780-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist