Provider Demographics
NPI:1770203036
Name:BOGACZ, TEJUN LEIGH (SLP-A)
Entity type:Individual
Prefix:
First Name:TEJUN
Middle Name:LEIGH
Last Name:BOGACZ
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18332 W CINNABAR AVE
Mailing Address - Street 2:
Mailing Address - City:WADDELL
Mailing Address - State:AZ
Mailing Address - Zip Code:85355-4352
Mailing Address - Country:US
Mailing Address - Phone:602-397-4334
Mailing Address - Fax:
Practice Address - Street 1:18332 W CINNABAR AVE
Practice Address - Street 2:
Practice Address - City:WADDELL
Practice Address - State:AZ
Practice Address - Zip Code:85355-4352
Practice Address - Country:US
Practice Address - Phone:602-397-4334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA132832355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty