=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255633483
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARCE' C HOTZ MS CCC-SLP, PC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2010
-----------------------------------------------------
Last Update Date | 11/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4924 FAWN RUN DR
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73099-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-823-8289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4924 FAWN RUN DR
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73099-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-823-8289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. MARCE' C HOTZ
-----------------------------------------------------
Credential | MS CCC-SLP
-----------------------------------------------------
Telephone | 405-823-8289
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2980
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------