MEDICARE: MR. OTTO MAZZONI III M.S., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	111590	TX

General Provider Information

NPI Number	:	1245725423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OTTO MAZZONI III M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	268 WHISPERING PINE TRL
Second Line	:
City	:	MOUNT VERNON
State	:	TX
Zip	:	75457-4957
Country	:	US
Telephone Number	:	903-563-2405
Fax Number	:

Provider Business Practice Location Address
First Line	:	2407 W MAIN ST # 82
Second Line	:
City	:	CLARKSVILLE
State	:	TX
Zip	:	75426-3327
Country	:	US
Telephone Number	:	903-427-3821
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2018
Last Update Date	:	06/29/2018

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Directions to “ MR. OTTO MAZZONI III M.S., CCC-SLP” Practice Location

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