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General NPI Number Information
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NPI Number | 1578925400
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Entity Type | Individual
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Provider Name | ETAN HAZIZA MA, CCC-SLP
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Gender | Male
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Dates
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Enumeration Date | 03/21/2016
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Last Update Date | 03/21/2016
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Provider Practice Location Address
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Address Line | 1 CEDAR CREST DR
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City | POMPTON PLAINS
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State | NJ
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Zip | 07444-2100
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Country | US
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Telephone | 973-831-1369
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Fax |
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Provider Business Mailing Address
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Address Line | 142 POMPTON AVE APT. 2
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City | VERONA
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State | NJ
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Zip | 07044-2936
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Country | US
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Telephone | 201-452-0671
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 41YS00811500
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License Number State | NJ
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