Basic Information
| Provider Information | |||||||||
| NPI: | 1245725423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZZONI | ||||||||
| FirstName: | OTTO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.S., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 268 WHISPERING PINE TRL | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754574957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035632405 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2407 W MAIN ST # 82 | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754263327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034273821 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2018 | ||||||||
| LastUpdateDate: | 06/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 111590 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.