Provider Demographics
NPI:1962939900
Name:FAZEKAS, KATHRYN L
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:FAZEKAS
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 1:130 ONYX PL
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-1904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:960 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-2722
Practice Address - Country:US
Practice Address - Phone:330-989-5091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP7530235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist