Provider Demographics
NPI:1952631566
Name:PEROZICH, MARY T (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:PEROZICH
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11161 E STATE 70
Mailing Address - Street 2:#110-819
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202
Mailing Address - Country:US
Mailing Address - Phone:412-303-0694
Mailing Address - Fax:
Practice Address - Street 1:1303 LIMIT AVE
Practice Address - Street 2:STE.201
Practice Address - City:MT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757
Practice Address - Country:US
Practice Address - Phone:352-508-7789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105551235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist