Provider Demographics
NPI:1285143958
Name:MARDANZAI, FARAH
Entity type:Individual
Prefix:
First Name:FARAH
Middle Name:
Last Name:MARDANZAI
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 1:2922 HEIRLOOM LN
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-6667
Mailing Address - Country:US
Mailing Address - Phone:812-340-3504
Mailing Address - Fax:
Practice Address - Street 1:2922 HEIRLOOM LN
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-6667
Practice Address - Country:US
Practice Address - Phone:812-340-3504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003922A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist