Provider Demographics
NPI:1841784998
Name:MAZZARO, MARISA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:MAZZARO
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 KOALA CT
Mailing Address - Street 2:
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-1800
Mailing Address - Country:US
Mailing Address - Phone:917-697-4237
Mailing Address - Fax:
Practice Address - Street 1:166 PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702
Practice Address - Country:US
Practice Address - Phone:732-842-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00922300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist