Provider Demographics
NPI:1336872811
Name:HALICZER, MARA LEAH (SLP)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:LEAH
Last Name:HALICZER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:
Other - Last Name:KATZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 LIBERTY PKWY APT A10
Mailing Address - Street 2:
Mailing Address - City:SAINT ROBERT
Mailing Address - State:MO
Mailing Address - Zip Code:65584-4875
Mailing Address - Country:US
Mailing Address - Phone:973-508-9957
Mailing Address - Fax:
Practice Address - Street 1:114 LIBERTY PKWY APT A10
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-4875
Practice Address - Country:US
Practice Address - Phone:973-508-9957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-02
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022010152235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2022010152OtherMISSOURI STATE BOARD - HEALING ARTS