Provider Demographics
NPI:1700933181
Name:MAZURCZAK, BETHANNE NARDO (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:BETHANNE
Middle Name:NARDO
Last Name:MAZURCZAK
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:MISS
Other - First Name:BETHANNE
Other - Middle Name:
Other - Last Name:NARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2337 SWAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-453-2919
Mailing Address - Fax:
Practice Address - Street 1:2895 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151
Practice Address - Country:US
Practice Address - Phone:262-782-9015
Practice Address - Fax:262-782-9013
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI842154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist