Provider Demographics
NPI:1477393148
Name:KOTZBAUER, ALYSSA MARIE (SLP-CCC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:KOTZBAUER
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13010 W JADESTONE DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-3244
Mailing Address - Country:US
Mailing Address - Phone:623-810-4396
Mailing Address - Fax:
Practice Address - Street 1:13010 W JADESTONE DR
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-3244
Practice Address - Country:US
Practice Address - Phone:623-810-4396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP14701235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist