Basic Information
Provider Information | |||||||||
NPI: | 1952503641 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PILCZUK | ||||||||
FirstName: | ZACHARY | ||||||||
MiddleName: | EDWIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3146 VERMONT AVE SW | ||||||||
Address2: |   | ||||||||
City: | GRANDVILLE | ||||||||
State: | MI | ||||||||
PostalCode: | 494181676 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2900 CHARLEVOIX DR SE | ||||||||
Address2: | STE 200 | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495467085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8006341077 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 5005875-4102 | UT | X |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 2202004997 | VA | X |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 0517191505 | MD | X |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.