Provider Demographics
NPI:1568284016
Name:RADOSEVICH, BREANNA R
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:R
Last Name:RADOSEVICH
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 1:15249 W GEORGIA DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-8184
Mailing Address - Country:US
Mailing Address - Phone:951-775-0667
Mailing Address - Fax:
Practice Address - Street 1:15116 N COTTON LN
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-9618
Practice Address - Country:US
Practice Address - Phone:623-322-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP14117235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist