Healthcare Provider Details

I. General information

NPI: 1265704829
Provider Name (Legal Business Name): PATRICIA MARY MRAZ CCC-SLP/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2012
Last Update Date: 01/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W 103RD ST LUDDEN CLINIC
CHICAGO IL
60655-3105
US

IV. Provider business mailing address

10654 GIGI DR
ORLAND PARK IL
60462-2879
US

V. Phone/Fax

Practice location:
  • Phone: 177-329-8357
  • Fax:
Mailing address:
  • Phone: 708-280-8933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146007880
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: