Provider Demographics
NPI:1962973230
Name:GERZETICH, MOLLY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:GERZETICH
Suffix:
Gender:F
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 1:9721 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-9432
Mailing Address - Country:US
Mailing Address - Phone:734-652-1900
Mailing Address - Fax:
Practice Address - Street 1:610 W ELM AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-7909
Practice Address - Country:US
Practice Address - Phone:734-240-9670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101002575235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist