Provider Demographics
NPI:1457891665
Name:MONDLOCH, BEVERLY KOOGLE
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:KOOGLE
Last Name:MONDLOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 BRASSWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7127
Mailing Address - Country:US
Mailing Address - Phone:410-913-8479
Mailing Address - Fax:
Practice Address - Street 1:241 BRASSWOOD CT
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7127
Practice Address - Country:US
Practice Address - Phone:410-913-8479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13340235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist