Basic Information
Provider Information | |||||||||
NPI: | 1114230869 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZOLLOS | ||||||||
FirstName: | BONNIE | ||||||||
MiddleName: | ELLEN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JENSEN | ||||||||
OtherFirstName: | BONNIE | ||||||||
OtherMiddleName: | ELLEN | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.A. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 255 FRONT ST | ||||||||
Address2: |   | ||||||||
City: | BEREA | ||||||||
State: | OH | ||||||||
PostalCode: | 440171943 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4402434000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 255 FRONT ST | ||||||||
Address2: |   | ||||||||
City: | BEREA | ||||||||
State: | OH | ||||||||
PostalCode: | 440171943 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4402434000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2010 | ||||||||
LastUpdateDate: | 07/23/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP437405 | OH | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.