Basic Information
| Provider Information | |||||||||
| NPI: | 1710635610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPORYSZ | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SPORYSZ | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S., SLP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2245 ROGENE DR APT 102 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212093492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613010243 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11201 PEPPER RD | ||||||||
| Address2: | |||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210311201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105279505 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2022 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 10100 | MD | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.