Healthcare Provider Details

I. General information

NPI: 1275103202
Provider Name (Legal Business Name): MADISON MARIE ROZYCKI M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 01/10/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 BERN CT STE 140
SAN JOSE CA
95112-1242
US

IV. Provider business mailing address

911 BERN CT STE 140
SAN JOSE CA
95112-1242
US

V. Phone/Fax

Practice location:
  • Phone: 408-573-7720
  • Fax:
Mailing address:
  • Phone: 408-573-7720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2021021277
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number33964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: