Healthcare Provider Details

I. General information

NPI: 1396651816
Provider Name (Legal Business Name): ROSE REY BAZYAR CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 E WINDEMERE AVE
ROYAL OAK MI
48073-5616
US

IV. Provider business mailing address

1613 E WINDEMERE AVE
ROYAL OAK MI
48073-5616
US

V. Phone/Fax

Practice location:
  • Phone: 586-928-3650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101008373
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: