Provider Demographics
NPI:1558644609
Name:MUCHA, JASON EDWARD (CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:EDWARD
Last Name:MUCHA
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:TULLY
Mailing Address - State:NY
Mailing Address - Zip Code:13159-3226
Mailing Address - Country:US
Mailing Address - Phone:315-696-6443
Mailing Address - Fax:
Practice Address - Street 1:9530 BREWERTON RD
Practice Address - Street 2:BREWERTON ELEMENTARY SCHOOL
Practice Address - City:BREWERTON
Practice Address - State:NY
Practice Address - Zip Code:13029-9788
Practice Address - Country:US
Practice Address - Phone:315-668-4201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12007685235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist