Provider Demographics
NPI:1851602643
Name:MAZZUCCO, SANDRA BETH (MA CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:BETH
Last Name:MAZZUCCO
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 1:1076 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2405
Mailing Address - Country:US
Mailing Address - Phone:718-815-6024
Mailing Address - Fax:
Practice Address - Street 1:1076 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2405
Practice Address - Country:US
Practice Address - Phone:718-815-6024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002642-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist